Exam 3 - ATI

A nurse in a provider’s office is preparing to assess a young adult client’s musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse EXPECT? (select all that apply)

A. concave thoracic spine posteriorly

B. exaggerated lumbar curvature

C. Concave lumbar spine posteriorly

D. exaggerated thoracic curvature

E. muscles slightly larger on the dominant side

C. concave lumber spine posteriorly

E. muscles slightly larger on the dominant side

A nurse, who is assessing a client’s neurologic system, should ask the client to close their eyes and identify which of the following items?

A. a word the nurse whisper 30 cm from the ear

B. a number the nurse traces on the palm of the hand

C. the vibration of a tuning fork the nurse places on the foot

D. a familiar object the nurse places in the hand

D. a familiar object the nurse places in the hand

A nurse is caring for a client who reports pain with internal rotation of the right shoulder. This discomfort can affect the client’s ability to perform which of the following activities?

A. exercising the deltoid muscle when using hand weights

B. brushing the hair on the back of the head

C. fastening or zipping closures on the back while dressing

D. reaching into a cabinet above the sink

C. fastening or zipping closures on the back while dressing

A nurse is performing a neurologic examination for a client. Which of the following assessments should the nurse perform to test the client’s balance? (select all that apply)

A. romberg test

B. heel-to-toe walk

C. snellen test

D. spinal accessory function

E. rosenbaum test

A. romberg test

B. heel-to-toe walk

A nurse is collecting data from an older adult client as part of a neurologic examination. Which of the following findings should the nurse expect as changes associated with aging? (select all that apply)

A. slower light touch sensation

B. some vision and hearing decline

C. slower fine finger movement

D. some short-term memory decline

E. decreased risk of depression

A. slower light touch sensation

B. some vision and hearing decline

C. slower fine finger movement

D. some short-term memory decline

A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should be included when explaining the procedure to the client?

A. eating more protein is optimal prior to testing

B. one stool specimen is sufficient for testing

C. a red color change indicates a positive test

D. the specimen cannot be contaminated with urine

D. the specimen cannot be contaminated with urine

A nurse is providing dietary teaching for a client who report constipation. Which of the following foods should the nurse recommend?

A. macaroni and cheese

B. one medium apple with skin

C. one cup of plain yogurt

D. roast chicken and white rice

B. one medium apple with skin

A nurse is assessing a client who has had diarrhea for 4 days. Which of the following findings should the nurse expect?

A. bradycardia

B. hypotension

C. elevated temperature

D. poor skin turgor

E. peripheral edema

B. hypotension

C. elevated temperature

D. poor skin turgor

While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take?

A. have the client hold their breath briefly and bear down

B. clamp the enema tubing

C. remind the client that cramping is common at this time

D. raise the level of the enema fluid container

B. clamp the enema tubing

A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following steps should the nurse take? (select all that apply)

A. warm the enema solution prior to instillation

B. position the client on the left side with the right leg flexed forward

C. lubricate the rectal tube or nozzle

D. slowly insert the rectal tube about 5 cm (2 in)

E. hang the enema container 61 cm (24 in) above the client’s anus

A. warm the enema solution prior to instillation

B. position the client on the left side with the right leg flexed forward

C. lubricate the rectal tube or nozzle

A nurse is admitting a client who has a suspected myocardial infarction and a history of angina. Which of the following findings will help the nurse distinguish stable angina from an MI?

A. stable angina can be relieved with rest and nitroglycerin

B. the pain from an MI resolves in less than 15 min

C. the type of activity that causes an MI can be identified

D. stable angina can occur for longer than 30 min

A. stable angina can be relieved with rest and nitroglycerin

A nurse on a cardiac unit is reviewing the lab findings of a client who has a diagnosis of MI and reports that his dyspnea began 2 weeks ago. Which of the following cardiac enzymes would confirm the MI occurred 14 days ago?

A. CK-MB

B. troponin I

C. troponin T

D. myoglobin

C. troponin T

A nurse is caring for a client who asks why the provider prescribed a daily aspirin. Which of the following responses should the nurse make?

A. “aspirin reduces the formation of blood clots that could cause a heart attack”

B. “aspirin relieves pain due to MI”

C. “aspirin dissolves clots that are forming in your coronary arteries”

D. “aspirin relieves headaches that are caused by other medications”

A. “aspirin reduces the formation of blood clots that could cause a heart attack”

A nurse is teaching a client who has angina about a new prescription for metoprolol. Which of the following statements by the client indicates understanding of the teaching?

A. “I should place the tablet under my tongue”

B. “I should have my clotting time checked weekly”

C. “I will report any ringing in my ears”

D. “I will call my doctor if my pulse rate is less than 60”

D. “I will call my doctor if my pulse rate is less than 60”

A nurse is presenting a community education program on recommended lifestyle changes to prevent angina and MI. Which of the following changes should the nurse recommend be made first?

A. diet modification

B. relaxation exercises

C. smoking cessation

D. taking omega-3 capsules

C. smoking cessation

A nurse is caring for a client who has HF and reports increased SOB. Which of the following actions should the nurse take first?

A. obtain the client’s weight

B. assist the client into high-fowler’s position

C. auscultate lung sounds

D. check oxygen saturation with pulse oximeter

B. assist the client into high-fowler’s position

A nurse is teaching a client with HF about new prescriptions for furosemide and digoxin? Which of the following information should the nurse include? (select all that apply)

A. weigh daily, first thing each morning

B. decrease intake of potassium

C. expect muscle weakness while taking digoxin

D. hold digoxin if heart rate is less than 70/min

E. decrease sodium intake

A. weigh daily, first thing each morning

E. decrease sodium intake

A nurse is completing the admission assessment of a client who has suspected pulmonary edema. Which of the following manifestations are expected findings? (select all that apply)

A. tachypnea

B. persistent cough

C. increased urinary output

D. thick, yellow sputum

E. orthopnea

A. tachypnea

B. persistent cough

E. orthopnea

A nurse is talking with a client who has class I heart failure and asks about obtaining a ventricular assisting device (VAD). Which of the following statements should the nurse make?

A. “VADs are only implanted during heart transplantation

B. “a VAD helps to pace the heart”

C. “VADs are used when heart failure is not responsive to medications”

D. “A VAD is useful for clients who also have a chronic lung issue”

C. “VADs are used when heart failure is not responsive to medications”

A nurse is providing discharge teaching for a client who has heart failure and is on a fluid restriction of 2000 mL/day. The client asks the nurse how to determine the appropriate amount of fluids they are allowed. Which of the following statements is an appropriate response by the nurse?

A. “pour the amount of fluid you drink into an empty 2-liter bottle to keep track of how much you drink”

B. “each glass contains 8 ounces. there are 30 mL/oz, so you can have a total of 8 glasses or cups of fluid each day”

C. “this is the same as 2 quarts, or about the same as two pots of coffee”

D. “take sips of water or ice chips so you will not take in too much fluid”

A. “pour the amount of fluid you drink into an empty 2-liter bottle to keep track of how much you drink”

A nurse is screening a client for HTN. The nurse should identify that which of the following actions by the client increase the risk for HTN? (select all that apply)

A. drinking 8oz nonfat milk each day

B. eating popcorn at the movie theater

C. walking 1 mile daily at 12 min/mile pace

D. consuming 36 oz beer daily

E. getting a massage once a week

B. eating popcorn at the movie theater

D. consuming 36 oz beer daily

A nurse in an urgent care clinic is obtaining a history from a client who has type 2 diabetes mellitus and a recent diagnosis of HTN. This is the second time in 2 weeks that the client experienced hypoglycemia. Which of the following client data should the nurse report to the provider?

A. takes psyllium daily as a fiber laxative

B. drinks skin milk daily as a bedtime snack

C. takes metoprolol daily after meals

D. drinks grapefruit juice daily with breakfast

C. takes metoprolol daily after meals

A nurse is caring for a client who is admitted to the emergency department with a blood pressure of 266/147 mm Hg. The client reports a headache and double vision. The client states, “I ran out of my diltiazem 3 days ago, and I am unable to purchase more.” Which of the following actions should the nurse take first?

A. administer acetaminophen for headache

B. provide teaching regarding the importance of not abruptly stopping an antihypertensive

C. obtain IV access and prepare to administer an IV antihypertensive

D. call social services for a referral for financial assistance in obtaining prescribed medication

C. obtain IV access and prepare to administer an IV antihypertensive

A nurse is providing teaching for a client who has a new diagnosis of HTN and a new prescription for spironolactone 25 mg/day. Which of the following statements by the client indicates an understanding of the teaching?

A. “I should eat a lot of fruits and vegetables especially bananas and potatoes”

B. “I will report any changes in heart rate to my provider”

C. “I should replace the salt shaker on my table with a salt substitution”

D. “I will decrease the dose of this medication when I no longer have headaches and facial redness”

B. “I will report any changes in heart rate to my provider”

A nurse is providing discharge teaching for a client who has a prescription for furosemide 40 mg PO daily. The nurse should instruct the client to take this medication at which of the following times of day?

A. morning

B. immediately after lunch

C. immediately before dinner

D. Bedtime

A. morning