ATI - TEST 4 PRACTICE ASSESSMENT Flashcards Preview

NUR 102- Test 4 > ATI - TEST 4 PRACTICE ASSESSMENT > Flashcards

Flashcards in ATI - TEST 4 PRACTICE ASSESSMENT Deck (98):
1

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is planning care for a client who has a suspected myocardial infarction. Which of the following should the nurse administer first?

A. Nitroglycerin (Nitrotstat)
B. Aspirin (A.S.A)
C. Oxygen
D. Morphine Sulfate

C. Oxygen

2

ATI - TEST 4 PRACTICE ASSESSMENT

While reading a client's ECG tracing, the nurse should understand that the P wave reflects which of the following cardiac electrical activities?

A. Ventricular depolarization
B. Slow repolarization of ventricular Purkinje fibers
C. Atrial deporlarization
D. Early ventricular repolarization

C. Atrial deporlarization

3

ATI - TEST 4 PRACTICE ASSESSMENT

A client comes to the emergency department via ambulance to report severe radiating chest pain and SOB. The client appears restless, frightened, and slightly cyanotic. The provider prescribes oxygen by nasal cannula at 4 L/min stat, cardiac enzyme levels, IV fluids, and a 12-lead ECG. Which of the following actions should the nurse assisting with this client client's care first?

A. Attach the leads for a 12-lead ECG.
B. Obtain the blood sample.
C. Initiate oxygen therapy.
D. Insert the IV catheter.

C. Initiate oxygen therapy.

4

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is preparing a client for an echocardiogram the following day. Which of the following instruction should the nurse include about this test?

A. It might cause slight discomfort in the chest area.
B. It takes about 5 or 10 min.
C. It requires lying quietly on one side.
D. It is best to have no food or beverage the day of the test.

C. It requires lying quietly on one side.

Rationale:
For a Transthoracic Echocardiogram (TTE), the client lies quietly on the left side with slight head elevation. There is no reason for the client to be NPO. The test takes up to 1 hour and there is not discomfort as a transducer with conductive jelly is used on the chest.

5

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is reviewing the laboratory values on a client who has HTN. Blood tests are drawn and reveal the following results. Which of the following results should the nurse identify as critical?

A. Sodium 136 mEq/L
B. Potassium 2.3 mEq/L
C. Chloride 99 mEq/L
D. Calcium 10 mg/dL

B. Potassium 2.3 mEq/L

6

ATI - TEST 4 PRACTICE ASSESSMENT

The nurse is completing a medication review of a client who has elevated cholesterol levels and takes an anticoagulant. Which of the following should the nurse report to the provider?

A. Attempts to follow a low-fat diet.
B. Implements of cholesterol lowering agent.
C. Sprinkles flax seeds on breakfast food q day.
D. Uses garlic as a cholesterol lowering agent.

D. Uses garlic as a cholesterol lowering agent.

Rationale:
The nurse should be aware that the use of garlic to lower cholesterol may potentiate the action of anticoagulant medication and should report the finding to the provider.

7

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is caring for a client who enters the emergency department complaining of severe chest pain. Which of the following interventions should the nurse implement to determine if the client is experiencing a myocardial infarction?

A. Check the client's blood pressure
B. Auscultate heart tones
C. Perform a 12-lead ECG
D. Determine if the pain radiates to the left arm.

C. Perform a 12-lead ECG

8

ATI - TEST 4 PRACTICE ASSESSMENT

While auscultating a client's heart sounds, the nurse hears turbulence between the S1 and S2 heart sounds. The nurse should document this finding as which of the following?

A. A cardiac murmur
B. A third heart sound (S3)
C. An expected heart sound
D. A fourth heart sound (S4)

A. A cardiac murmur

Rationale:
Cardiac murmurs are relatively lout, turbulent sounds the nurse can hear between usual, expected heart sounds. They create a whooshing or swishing sound.

9

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is reviewing the initial laboratory values for partial thromboplastin time, and prothrombin time, and thrombin time on a client who has an acute episode of disseminated intravascular coagulation (DIC). The nurse should expect the laboratory values to be

A. normal.
B. prolonged.
C. decreased.
D. elevated.

B. prolonged.

Rationale:
The nurse should expect the laboratory values to be prolonged because the anticoagulant pathways are impaired and consume the key clotting factors, resulting in clotting dysfunction.

10

**ATI - TEST 4 PRACTICE ASSESSMENT**

A nurse is reinforcing discharge teaching for a client who has received an implantable cardioverter/defribillator (ICD). Which of the following information should the nurse include?

A. The client cannot travel by air due to security screening.
B. The client should hold his cell phone on the side opposite the ICD.
C. THe client should avoid the use of small electric devices.
D. The client can carry his ICD in a small pocket.

B. The client should hold his cell phone on the side opposite the ICD.

Rationale:
The client should keep his cellular phone on the side opposite of the ICD, as close proximity could interfere with the ICD's function. The client should inform airport security of the device. The client does not carry the ICD is in his pocket, this is an IMPLANTABLE device.

11

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is reinforcing teaching for a client who is postoperative following an insertion of a permanent pacemaker. Which of the following instructions should the nurse include? (Select all that apply.)

A. Count your pulse for 1 min each morning.
B. Count your respiratory rate for 1 min each morning.
C. Do not wear tight clothing over the insertion area.
D. Avoid coming into contact with metal detectors.
E. Do not operate microwave ovens.

A. Count your pulse for 1 min each morning.
C. Do not wear tight clothing over the insertion area.

Rationale:
Avoid coming into contact with metal detectors is incorrect, there is not danger going through a metal detector, but the client should inform airport security because the pacemaker will trigger an alarm.

Do not operate microwave ovens is incorrect. It is save for clients with a pacemaker to operate microwave ovens unless they are old and do not have the appropriate shielding or of they are defective.

12

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip?

A. The pacemaker spikes after each QRS complex.
B. The pacemaker spikes before each P wave.
C. The pacemaker spikes before each QRS complex.
D. The pacemaker spikes with each T wave.

C. The pacemaker spikes before each QRS complex.

13

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is about to administer warfarin (Coumadin) to a client who has atrial fibrillation. When the client asks what this medication will do, which of the following is an appropriate nursing response?

A. It helps convert the atrial fibrillation to sinus rhythm.
B. It dissolves clots in the bloodstream.
C. It slows the response of the ventricles to the fast atrial impulses.
D. It prevents strokes in clients who have atrial fibrillation.

D. It prevents strokes in clients who have atrial fibrillation.

Rationale:
Clients who have atrial fibrillation are at an increased risk for thrombus formation and subsequent embolization to the brain. Anticoagulants such as warfarin help prevent thrombosis formation.

14

ATI - TEST 4 PRACTICE ASSESSMENT

A client is telling the nurse in the clinic that he gets a headache after he takes sublingual nitroglycerin (Nitrostat). Which of the following should the nurse remind the client to do?

A. Reduce the nitroglycerin dose.
B. Ask the provider to prescribe a strong analgesic.
C. Lie down in a cool environment and rest.
D. Ask the provider to prescribe a different medication.

C. Lie down in a cool environment and rest.

Rationale:
HA is a common side effect of nitroglycerin. The nurse should suggest conservative measures to manage the HA. Generally, HAs that are a side effect of nitroglycerin are transient. They usually last about 5 min an rarely longer than 20 min.

15

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is reinforcing teaching for a client who has a new prescription for warfarin sodium (Coumadin). Which of the following should the nurse include?

A. Mild nosebleeds are common during initial treatment.
B. He should use an electric razor while on this medication.
C. If he misses a dose, he should double the dose at the next scheduled time.
D. Coumadin increases the risk for DVT.

B. He should use an electric razor while on this medication.

16

***ATI - TEST 4 PRACTICE ASSESSMENT***

A nurse is caring for a client who reports an area of redness, warmth, tenderness and pain in the right calf. The nurse anticipates which of the following orders when notifying the provider of this finding?

A. Obtain a venous duplex ultrasound.
B. Obtain impedance plethysmofraphy.
C. Monitor Homan's sign.
D. Apply cold therapy to the affect leg.

A. Obtain a venous duplex ultrasound.

Rationale:
Venous duplex utlrasonography is a noninvasive diagnostic test used to detect distal DVT. Performing Homan's sign and dislodge the clot therefore this is inappropropriate. Warm therapy is used with DVTs not cold therapy

17

**ATI - TEST 4 PRACTICE ASSESSMENT**

A client complains of SOB and chest pain the first day following multiple long bone fractures. THe nurse would consider which of the following client complications when assessing the client?

A. Pneumonia
B. Fat emboli
C. Cardiac dysrhythmia
D. Hypoxic condition

B. Fat emboli

Rationale:
The client with a compound long bone fracture is at high risk for developing a fat embolus within 24 to 96 hr.

18

***ATI - TEST 4 PRACTICE ASSESSMENT***

A nurse is collecting data from an infant that has a coarctation of the aorta. Which of the following is a clinical manifestation?

A. Increased blood pressure in the arms with decreased blood pressure in the legs
B. Decreased blood pressure in the arms with increased blood pressure in the legs
C. Severe generalized cyanosis
D. Pulmonary edema.

A. Increased blood pressure in the arms with decreased blood pressure in the legs

Rationale:
There is a narrowing next to the ductus areteriosus which results in an increased pressure proximal to the defect with a decreased distal to the obstruction. Therefore, an increase blood pressure in the arms with a decreased blood pressure in the legs would be a clinical manifestation of a coarctation of the aorta.

19

ATI - TEST 4 PRACTICE ASSESSMENT

When checking a client's capillary refill, the nurse finds that the color returns to usual in 10 seconds. The nurse understands that this finding indicates which of the following?

A. Arterial insufficiency
B. Venous insufficiency
C. Within the expected range
D. Thrombus formation

A. Arterial insufficiency

Rationale:
To test the capillary refill, the nurses presses on the client's nail beds to produce blanching and then measures the time it takes for the color to return. With adequate arterial capillary perfusion, the color should return within 3 seconds. Taking longer than 3 seconds indicates impaired arterial blood flow to the extremity.

20

ATI - TEST 4 PRACTICE ASSESSMENT

Whenever a nurse is caring for clients who are receiving heparin, which of the following medications should the nruse have on hand in the event of an overdose?

A. Iron
B. Glucagon
C. Protamine
D. Vitamin K

C. Protamine

21

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is caring for a client who takes nitroglycerin (Nitrostat) tablet at the onset of anginal pain. AFter taking the pill, the client states that his chest pain is relieved, but then he develops a sudden pounding headache. The nurse understands that the headache is

A. An orthostatic reaction.
B. A toxic adverse reaction.
C. A hypersensitivity reaction.
D. A common adverse reaction.

D. A common adverse reaction.

22

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is collecting data from a client who has HTN and has a prescription for propranolol (Inderal). A history of which of the following conditions should be reported to the provider?

A. Migraine
B. Glaucoma
C. Depression
D. Heart failure

D. Heart failure

Rationale:
Propanolol is used with caution in clients who have heart failure to to the depressive effect on the myocardial contractility; therefore, the nurse should report this finding to the provider.

23

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is caring for a client who is admitted with a DVT of the left leg. Which of the following interventions should the nurse include in the client's plan of care?

A. Application of ice to the extremity
B. Strict bedrest
C. Restriction of oral fluids
B. Administration of vasodilating medications

B. Strict bedrest

Rationale:
Bedrest is considered supportive therapy for DVT and should be included in the plan of care.

24

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is administering monitoring medications and realizes the nifedipine (Procardia) was administered to the wrong client. Which of the following is the priority nursing action?

A. Check the client's vital signs.
B. Notify the client's charge nurse.
C. Fill out an occurrence form according to institutional policy
D. Administer the medication to the correct client.

A. Check the client's vital signs.

Rationale:
Nifedipine is an antihypertensive medication. The nurse should immediately check the client's vital signs for any significant alterations an then notify the provider.

25

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is caring for a client who is admitted to the hospital with CHF who has been taking digoxin (Lanoxin) 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse perform first?

A. Suggest that the client rest before eating the meal.
B. Request a dietitian consult.
C. Check the client's vital signs.
D. Request an order for antiemetic.

C. Check the client's vital signs.

Rationale:
Nausea is a symptom of digoxin toxicity. The nurse should take the client's vital signs to determine if the client is experiencing bradycardia. The nurse should withhold the drug and call the provider if the client has bradycardia.

26

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is reinforcing teaching regarding diet to a client after a myocardial infarction. The nurse evaluates the reinforcement as effective if the client selects which of the following options?

A. Barbecued beef, baked beans, potato chips and a tossed salad.
B. Baked turkey, mashed potatoes, squash and salad.
C. Bread, fried fish patty, potato salad and cole slaw.
D. Grilled pork chops, biscuits and brown gravy, sliced tomato.

B. Baked turkey, mashed potatoes, squash and salad.

Rationale:
Low sodium, low fat diet is usual cardiac diet.

27

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is contributing to the care plan for a client who has developed DVT. Which of the following interventions should the nurse include?

A. Apply cold compresses to the affect extremity.
B. Masse the affected extremity gently.
C. Elevate the affected extremity when the client is resting.
D. Limit the client's fluid intake to 1 L/day

C. Elevate the affected extremity when the client is resting.

Rationale:
Supportive treatment for DVT includes elevation of the extremity when the client is in bed or in a chair.

28

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is helping with the admission of a client from the emergency department. The client is prescribed clopidogrel bisulfate (Plavix). Which of the following precautions should the nurse anticipate?

A. Bleeding
B. Neutropenic
C. Airborne
D. Seizure

A. Bleeding

Rationale:
Plavix is an antithrombotic and antiplatelet aggregate used to lessen the chance of a heart attack or stroke. Bleeding precautions are implemented to limit client exposure to injury-causing events that may lead to internal or external bleeding.

29

***ATI - TEST 4 PRACTICE ASSESSMENT***

A nurse is caring for an infant who has a congenital heart defect. Which of the following is associated with increased pulmonary blood flow?

A. Coarctation of the aorta
B. Patent ductus arteriosus
C. Tetralogy of Fallot
D. Tricuspid atresia

B. Patent ductus arteriosus

Rationale:
With patent ductus arteriosus, the area between the pulmonary artery and aorta remains open, allowing the blood to flow through the patent ductus arteriousus and back to the pulmonary artery and lungs.

30

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse on a telemetry unit is caring for a client who has premature ventricular contractions (PVCs). While sitting in a chair, the client reports feeling lightheaded. If the client is having PVCs, which of the following findings should the nurse expect when auscultating the client's apical pulse?

A. Bounding pulsations
B. Irregular pulsations
C. Tachycardia
D. Bradycardia

B. Irregular pulsations

Rationale:
PVCs are early ventricular depolarization that cause a pause immediately afterwards. The pause in the usual heart rhythm results in an irregular apical pulse. PVCs have a wide variety of causes, and the client typically perceives them as "palpitations."

PVCs = feelings of heart skipping a beat!


31

***ATI - TEST 4 PRACTICE ASSESSMENT***

In preparation for the discharge of a client with peripheral arterial disease PAD, the nurse should reinforce which of the following instructions?

A. Apply a heating pad on a low setting to help relieve leg pain.
B. Adjust the thermostat so that the environment is warm.
C. Wear antiembolic stockings during the day.
D. Rest with the legs above heart level.

B. Adjust the thermostat so that the environment is warm.

Rationale:
Clients who have PAD should not wear any constrictive clothing.

32

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is talking with a client who is about to start using transdermal nitroglycerin (Nitro-Dur) to treat angina pectoris. Which of the following is an appropriate instruction for this medication therapy?

A. Apply a new transdermal patch once a week.
B. Apply the transdermal patch in the morning.
C. Apply the transdermal patch below the level of the waist.
D. Wait 24 hours to apply a new patch if the applied patch falls off.

B. Apply the transdermal patch in the morning.

Rationale:
The client should apply the patch every morning after showering and leave it in place for a minimum of 12 hours.

33

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is caring for a client on a medical surgical unit with a DVT who has been on IV heparin for 5 days. The provider prescribes oral warfarin (Coumadin) without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following is an appropriate response by the nurse?

A. "Heparin enhances the effects of warfarin."
B. "I plan to have the charge nurse call your provider to get an explanation."
C. "Both heparin and warfarin work together to dissolve the clots."
D. "Heparin will be continued until the warfarin reaches a therapeutic level."

D. "Heparin will be continued until the warfarin reaches a therapeutic level."

Rationale:
Heparin and warfarin are both anticoagulants that decrease the clotting ability of the blood and help prevent thrombosis formation in the blood vessels. However, they work in different ways to achieve therapeutic coagulation and must be given together until therapeutic levels of anticoagulation can be achieved by warfarin alone, which usually occurs within 1 to 5 days. When PT and INR are within therapeutic range, the heparin can be discontinued.

34

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is caring for a client who just had a cardiac catheterization. The post procedure nursing care plan for this client should include which of the following nursing interventions?

A. Have the client rest in bed for 2 to 6 hr.
B. Keep the involved leg slightly flexed.
C. Elevate the HOB 45º.
D. Keep the client NPO for 4 hr.

A. Have the client rest in bed for 2 to 6 hr.

Rationale:
Clients who had manual or mechanical pressure after catheter removal require 6 hr of bed rest. Those who had a closure device or patch only need 2 hr of bed rest.

35

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is caring for a client who enters the emergency department complaining of chest pressure and severe epigastric distress. The physician prescribes monitoring of creatine kinase (CK) isoenzymes. The nurse should paln to monitor these levels over which of the following lengths of time?

A. 1 hr
B. 4 hr
C. 12 hr
D. 24 hr

D. 24 hr

36

ATI - TEST 4 PRACTICE ASSESSMENT

A client who has angina pectoris is experiencing chest pain and has taken three nitroglycerin tablets sublingually. The client reports relief from the chest pain but now repots a headache. The nurse should explain to the clients that this symptom

A. could mean an allergy to the medication.
B. is an expected side effect of the medication.
C. indicates tolerance to the medication
D. is probably a result of anxiety about the chest pain.

B. is an expected side effect of the medication.

37

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is reinforcing teaching with a young adult female client who has been prescribed lisinopril (Zestril). Which of the following instructions should the nurse plan to include? (Select all that apply.)

A. "Report the development of a persistent dry cough."
B. "Monitor your blood pressure on a regular basis."
C. "Notify your doctor immediately if you become pregnant."
D. "Check your weight at the same time every day."
E. "Make sure your diet contains a lot of potassium-rich foods."

A. "Report the development of a persistent dry cough."
B. "Monitor your blood pressure on a regular basis."
C. "Notify your doctor immediately if you become pregnant."

38

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is reinforcing teaching with a client who was recently diagnosed with Raynaud's phenomenon how to prevent the onset of manifestations. Which of the following statements by the client should indicate to the nurse a need for FURTHER teaching?

A. "I will keep my house at a cool temperature."
B. "I will try to anticipate and avoid stress situations."
C. "I will complete the smoking cessation program I started."
D. "I will wear gloves when removing food from the freezer."

A. "I will keep my house at a cool temperature."

Rationale:
Raynaud's phenomenon occurs when the client is exposed to cold temperatures or stress causing painful vasoconstriction of the blood vessels in the periphery. Keeping the house warm would help prevent manifestations of Raynaud's phenomenon.

39

ATI - TEST 4 PRACTICE ASSESSMENT****

A nurse on a medical unit is caring for a client who has angina pectoris and reports chest pain with a severity of 6 on a 0 to 10 scale. The nurse administers sublingual nitroglycerin (Nitrostat). After 5 min, the client states that his chest pain is now a 2. Which of the actions should the nurse take?

A. Administer another nitroglycerin tablet.
B. Measure the client's blood pressure.
C. Check the client's apical heart rate.
D. Obtain an ECG.

A. Administer another nitroglycerin tablet.

Rationale:
Administration guidelines for sublingual nitroglycerin indicate that is appropriate to administer another tablet 5 min after the first if the client is still reporting pain.

40

ATI - TEST 4 PRACTICE ASSESSMENT

Whenever a nurse is caring for clients who are receiving warfarin (Coumadin), which of the following medications should the nurse have on hand in the even of an overdose?

A. Epinephrine
B. Atropine
C. Protamine
D. Vitamin K

D. Vitamin K

41

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is caring for a client with right-sided heart failure. The nurse knows that a primary manifestation is

A. frothy sputum
B. dyspnea
C. orthopnea
D. peripheral edema

D. peripheral edema

42

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is reinforcing discharge teaching for a client who will be taking warfarin (Coumadin) at home. Which of the following statements indicates that the client understands the effects of this medication?

A. "It's okay to have a couple of glasses of wine with dinner."
B. "I'll be sure to eat foods with lots of vitamin K."
C. "I'll take aspirin for my headaches."
D. "I'll use my electric razor for shaving."

D. "I'll use my electric razor for shaving."

43

***ATI - TEST 4 PRACTICE ASSESSMENT***

A nurse is caring for a client who is to receive digoxin (Lanoxin), verapamil (Calan), and baby aspirin (ASA) at 0900. Morning vital signs reported by the AP to the nurse include, temperature 37ºC (98.6ºF), heart rate 98/min, respiratory rate 24/min, BP 98/58 mm Hg. Which of the following actions should the nurse take?

A. Administer the morning medications.
B. Recheck the client's blood pressure.
C. Hold the medications and recheck the vital signs in one hour.
D. Recheck the client's pulse.

B. Recheck the client's blood pressure.

Rationale:
The nruse notes that the BP obtained is below the expected reference range for a client receiving an antihypertensive medication. Verapamil (Calan) is a calcium channel blocker used for treatment of angina, hypertension and arrhythmias. The nurse should verify that this blood pressure reading is accurate, then, depending on the result obtained would either administer or hold the verapamil.

44

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is caring for a client following a cardiac catheterization. Which of the following is an appropriate nursing action?

A. Monitor pedal pulses q15 min.
B. Perform passive range of motion of the affected extremity.
C. Ambulate the client when he is awake and alert.
D. Keep the client in high-Fowler's position for 6 hr.

A. Monitor pedal pulses q15 min.

45

ATI - TEST 4 PRACTICE ASSESSMENT

A client with valvular heart disease is at risk for developing left-sided heart failure. The nurse knows to monitor which of the following parameters to determine if the client has developed this disorder?

A. Appetite
B. Body weight
C. Breath sounds
D. Blood pressure

C. Breath sounds

Rationale:
Classic manifestations of left-sided heart failure are crackles or wheezes, which the nurse can identify by monitoring the client's breath sounds.

46

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is collecting data from an older adult client who is receiving digoxin (Lanoxin). To evaluate the client for digoxin toxicity, the nurse should check for which of the following manifestations?

A. Anorexia
B. Ataxia
C. Photosensitivity
D. Jaundice

A. Anorexia

47

ATI - TEST 4 PRACTICE ASSESSMENT

A client tells the nurse that he is concerned because his doctor told him he has a heart murmur. The nurse should explain to the client that a murmur

A. is a high-pitch sound due to a narrow valve.
B. is an extra sound due to blood entering an inflexible chamber.
C. means there is some inflammation around your heart.
D. indicates turbulent blood flow through a valve

D. indicates turbulent blood flow through a valve

Rationale:
Turbulent blood tow through a valve generates a murmur, possibly due to a malfunctioning valve, increased blood flow, or some type of defect in the structures of or around the heart.

48

ATI - TEST 4 PRACTICE ASSESSMENT

A client who is postoperative following surgical placement of an artificial heart valve is to be regulated on warfarin (Coumadin) prior to discharge. The nurse should use the results of which of the following diagnostic tests to monitor the effect of this therapy?

A. Prothrombin time (PT)
B. Platelet count
C. Activated coagulation time (ACT)
D. Activated partial thromboplastin time (aPTT)

A. Prothrombin time (PT)

Rationale:
The PT, reported as an INR, is used to monitor warfarin therapy.

49

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse in a provider's office is collecting data from a client who reports shortness of breath in the supine position and fatigue. The nurse determines that the client also has a jugular vein distention and a third heart sound (S3). Which of the following disorders should the nurse suspect?

A. Aortic regurgitation
B. Mitral stenosis
C. Aortic stenosis
D. Mitral valve prolapse

D. Mitral valve prolapse

Rationale:
Although many clients with mitral valve prolapse are asymptomatic, others report atypical chest pain, palpitations, exercise intolerance, dizziness, and syncope. Findings include a midsystolic click and a late systolic murmur.

50

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is giving a presentation about caring for clients who are receiving diuretic therapy to treat heart failure. THe nurse should explain that which of the following medications puts clients at risk for both hyperkalemia and hyponatremia?

A. Furosemide (Lasix)
B. Hydrochlorothiazide (HCTZ)
C. Mannitol (Osmitrol)
D. Spironolactone (Aldactone)

D. Spironolactone (Aldactone)

Rationale:
Spironolactone is a potassium-sparing diuretic. It blocks the effects of aldosterone in the renal tubules, causing a loss of sodium and water of potassium. Thus possible adverse reaction include hyperkalemia and hyponatremia.

51

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is reinforcing teaching for a client who has angina pectoris about starting therapy with nitroglycerin (Nitrostat) sublingual tablets. The nurse verifies the client's understanding when the client states

A. "I'll dial 911 if I still have pain after taking three tablets 5 minutes apart."
B. "I'll dial 911 if I still have pain after taking four nitroglycerin tablets over a 20 minute period."
C. I'll dial 911 if I still have pain and then take the nitroglycerin tablets.
D. I'll dial 911 if one tablet does not relieve my pain and then take up to two more 5 minutes apart while waiting.

D. I'll dial 911 if one tablet does not relieve my pain and then take up to two more 5 minutes apart while waiting.

Rationale:

52

ATI - TEST 4 PRACTICE ASSESSMENT***

A nurse is reinforcing teaching for an older adult client who has just undergone insertion of a permanent pacemaker. The nurse should emphasize that a sign of pacemaker malfunction the client should report to the provider is

A. increased urine output.
B. rapid pulse
C. fatigue.
D. sneezing

C. fatigue.

Rationale:
Pacemaker malfunction causes bradycardia and a drop in cardiac output. This can cause hypoxia, with classic manifestations of weakness, fatigue, and dizziness.

53

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is caring for a client who has left-sided heart failure. Which of the following findings should the nurse expect?

A. Frothy sputum.
B. Dependent edema
C. Nocturnal polyuria
D. Jugular distention.

A. Frothy sputum.

Rationale:
Left-sided heart failure reduces cardiac output and raises pulmonary venous pressure. Manifestations include hacking cough, frothy sputum, wheezing, fatigue, and weakness.

54

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is reviewing the morning laboratory results of electrolytes of four cardiac clients who are receiving digoxin (Lanoxin). Which of the clients should the nurse identify as being at risk for developing digoxin toxicity?

A. A client taking furosemide (Lasix) for chronic HTN.
B. A client taking chloropamide (Diabinese) for type 2 diabetes mellitus.
C. A client taking aluminum hydroxide (Amphojel) for gastric upset.
D. A client taking a potassium supplement (K-Dur) twice a day.

A. A client taking furosemide (Lasix) for chronic HTN.

Rationale:
Loop diuretics such as furosemide, may cause hypokalemia, which greatly increases the risk of digoxin toxicity.

55

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is caring for a client who takes linsinopril (Zestril) should monitor for which of the following medication therapy?

A. Insomnia
B. Hypotension
C. Hypokalemia
D. Anemia

B. Hypotension

Rationale:
Linsopril, an ACE inhibitor, is used to treat hypertension and heart failure. However, in reducing blood pressure, it is possible that the client will become hypotensive.

56

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is reading a client's ECG tracing. There are nine QRS complexes in a 6-second interval. What is the client's heart rate?

_____ per min

90

57

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is collecting data from a client who has an acute myocardial infarction (MI). Which of the following clinical manifestations should the nurse expect to find? (Select all that apply.)

A. Orthopnea
B. Headache
C. Nausea
D. Tachycardia
E. Diaphoresis

C. Nausea
D. Tachycardia
E. Diaphoresis

Rationale:
Orthopnea is incorrect. It is a manifestation of heart failure., which can develop from a myocardial infarction, but it is not a common manifestation of acute MI.

HA is incorrect. Chest pain and sometimes jaw and shoulder pain, not HA, are classic manifestations.

Tachycardia is correct. Tachycardia and dysrhythmias are classic manifestations of acute MI.

Diaphoresis is correct. Profuse sweating and anxiety are classic manifestations of acute MI.

58

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is talking with a client who has hypertension and stable angina pectoris and is about to start taking verapamil (Calan). The nurse should instruct the client to avoid taking this medication with

A. milk.
B. orange juice.
C. coffee.
D. grapefruit juice.

D. grapefruit juice.

Rationale:
Large amounts of grapefruit juice increase blood levels of verapamil, a calcium channel blocker, by inhibiting its metabolism. The excess amount of drug can intensify the medication's hypotensive effects, putting the client at risk for syncope and dizziness.

59

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is talking with a client who is about to start using sublingual nitroglycerin (Nitrostat) to treat angina pectoris. The client asks the nurse how long he has to take the medication before his condition is cured. The nurse should first

A. ask the client what he knows about his diagnosis.
B. make sure the client knows how to take his medication.
C. provide the client with written information about angina pectoris.
D. explain that the medication may help control the client's symptoms.

A. ask the client what he knows about his diagnosis.

Rationale:
The first action the nurse should take using the nursing process is to assess or collect data from the client. The nurse should find out what the client knows and correct any mispreconceptions before proceeding with further instructions.

60

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is reading a client's ECG tracing. Which component of the ECG should the nurse examine to determine the time it takes for ventricular depolarization and repolarization?

A. PR interval
B. QT interval
C. ST segment
D. QRS complex

B. QT interval

Rationale:
The QT interval reflects the time it takes for ventricular depolarization. The nurse should measure the QT interval from the start of the QRS complex to the end of the T wave.

61

ATI - TEST 4 PRACTICE ASSESSMENT

To evaluate the client following a cardiac catheterization with a left antecubital insertion site, the nurse should palpate the

A. brachial pulse in the left arm
B. brachial pulse in the right arm
C. radial pulse in the left arm.
D. radial pulse in the right arm.

C. radial pulse in the left arm.

Rationale:
Palpating the client's pulse distal to the insertion site is essential for evaluating for thrombophlebitis and vessel occlusion. The left radial pulse should be bilateral and strong.

62

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is caring for a client with cirrhosis who has a prothrombin time of 30 seconds. Which of the following medications does the nurse anticipate the provider will prescribe?

A. Vitamin K
B. Heparin
C. Warfarin
D. Ferrous sulfate

A. Vitamin K

Rationale:
A prothrombin time of 30 seconds indicates the clotting time is prolonged and bleeding could occur. Vitamin K injection increases the synthesis of prothrombin by the liver, therefore; the nurse should anticipate the provider will prescribe Vitamin K.

63

ATI - TEST 4 PRACTICE ASSESSMENT

A client experiencing erectile dysfunction asks the nurse about the possibility of a sildenafil (Viagra) prescription. The nurse informs the client that sildenafil is contraindicated due to the fact that the client also takes

A. isosorbide (Isordil)
B. phenytoin (Dilantin)
C. metformin (Glucophage)
D. prednisone (Deltasone)

A. isosorbide (Isordil)

Rationale:
Sildenafil, a medication used to treat impotence in men, increases the body's ability to achieve and maintain an erection during sexual stimulation. Isosorbide is a nitrate medication used to prevent or treat angina. Clients who are on nitrates, including isosorbide and nitroglycerin preparations, should not take sildenafil due to the potential for severe hypotension.

64

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is making a home visit to a client who receives diuretics daily for heart failure. Which of the following signs would the client manifest with hypokalemia?

A. Pitting edema
B. Fatigue
C. Dyspnea
D. Oliguria

B. Fatigue

Rationale:
The nurse should expect to find the client with fatigue due to muscle weakness with hypokalemia.

65

ATI - TEST 4 PRACTICE ASSESSMENT

A client has a new prescription for transdermal (Nitro-Dur) to treat angina pectoris. When talking with the patient about using this drug, the nurse should include which of the following instructions? (Select all that apply)

A. Apply the patch to a hairless area and rotate sites.
B. Apply a new patch each morning.
C. Remove the patch for 10 to 12 hr daily.
D. Apply the patch to dry skin and cover the area with plastic wrap.
E. Apply a new patch at the onset of anginal pain.

A. Apply the patch to a hairless area and rotate sites.
B. Apply a new patch each morning.
C. Remove the patch for 10 to 12 hr daily.

Rationale:
Apply the patch to dry skin and cover the area with plastic wrap is incorrect. These instructions apply to topical nitroglycerin ointment, not to nitroglycerin patches.

Apply a new patch at the onset of anginal pain is incorrect. Nitroglycerin patches prevent angina attacks. They do not treat angina attacks.

66

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is assessing a client who has right ventricular failure. Which of the following findings should the nurse expect?

A. A dry, hacking cough
B. Hepatomegaly
C. Dizziness
D. Crackles

B. Hepatomegaly

Rationale:
Hepatomegaly, or liver enlargement, is a manifestation of right-sided heart failure.

67

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is caring for a child who has tetralogy of Fallot and notes that the child is easily fatigued. The nurse understands that the etiology (the cause) of the fatigue is which of the following?

A. Inadequate intake of high-calorie foods and vitamins
B. Poor muscular the tone and development
C. Inadequate oxygenation for supporting energy metabolism
D. Restricted blood flow leaving the heart.

C. Inadequate oxygenation for supporting energy metabolism

Rationale:
Fatigue is a direct result of the child circulating poorly oxygenated blood due to left-to-right shunting of blood.

68

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back and shoulder, SOB and nausea. Which of the following actions should the nurse perform first?

A. Administer oxygen.
B. Begin ECG monitoring.
C. Ensure a patent airway.
D. Assess pain using the pain scale (0 to 10).

C. Ensure a patent airway.

Rationale:
Using the ABC priority setting framework, maintaining a patent airway is the first action the nurse should take.

69

ATI - TEST 4 PRACTICE ASSESSMENT***

A nurse is reinforcing discharge teaching to a client who was prescribed verapamil (Calan) for angina. Which of the following information should the nurse include?

A. Take with a daily aspirin.
B. Take between meals.
C. Sprinkle capsule contents on food.
D. Lowers cholesterol.

C. Sprinkle capsule contents on food.

Rationale:
The nurse should include in the teaching that the client may open the capsule and sprinkle on food if having difficulty swallowing.

70

ATI - TEST 4 PRACTICE ASSESSMENT***

A nurse is caring for a client who is postoperative following vascular surgery. Which of the following signs should indicate to the nurse that the client has developed a thrombus?

A. Positive Kernig's sign
B. Positive Homan's sign
C. Dull, aching, calf pain
D. Soft, pliable calf muscle.

C. Dull, aching, calf pain

Rationale:
Homan's sign is unreliable as only a small percentage of clients who have a thrombus develop it, and performing it could mobilize the clot.

71

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder? (Select all that apply.)

A. Genetic predisposition
B. Hypercholesterolemia
C. Hypertension
D. Obesity
E. Smoking.

B. Hypercholesterolemia
C. Hypertension
D. Obesity
E. Smoking.

72

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is collecting data from an infant. Which of the following is a clinical manifestation of a large patent ductus arteriosus?

A. Cyanosis with crying
B. Machinery-like murmur
C. Weak pulses
D. Chronic hypoxemia

B. Machinery-like murmur

Rationale:
A patent ductus arteriosus is failure of the artery connecting the aorta and pulmonary artery to close after birth causing a left-to-right shunt. A machinery-like murmur is a clinical manifestation found in infants with a large patent ductus arteriosus.

73

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is obtaining vital signs on a client who is 3 days postoperative following a coronary artery bypass surgery (CABG), and notes that the client has in irregular radial pulse of 92/min. Which of the following actions should the nurse take first?

A. Check the pulse in each of the client's extremities.
B. Notify the charge nurse of the client's heart rate.
C. Count the apical heart rate for 1 minute.
D. Obtain the other vital signs and document the findings.

C. Count the apical heart rate for 1 minute.

Rationale:
When obtaining a radial pulse the nurse should count the pulse for 15 seconds and multiply the result by 4. However, this method will not result in an accurate heart rate for a client with an irregular heart rhythm. If the nurse finds that the pulse is irregular, the apical heart rate is then counted for a full minute in order to obtain the most accurate result.

74

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is talking with a client who is about to start taking captopril (Capoten) to treat hypertension. Which of the following instructions should the nurse include to help the client manage this medication's adverse effects?

A. Do not use salt substitutes while taking this medication.
B. Eat a meal before taking the medication.
C. Count your pulse rate before taking the medication.
D. Expect to gain weight while taking this medication.

A. Do not use salt substitutes while taking this medication.

75

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is admitting a client who has acute heart failure following an MI and is reviewing the provider's orders. Which of the following prescriptions by the provider requires clarification?

A. Morphine sulfate 2 mg IV bolus q2h prn for pain.
B. Laboratory testing of serum potassium upon admission.
C. 0.9% NS IV at 50 mL/hr continuous
D. Bumetanide (Bumex) 1 mg IV bolus q12h.

C. 0.9% NS IV at 50 mL/hr continuous

Rationale:
0.9% sodium chloride is isotonic and will not cause the fluid shift needed in this client to reduce circulatory overload. This prescription requires clarificaton.

76

ATI - TEST 4 PRACTICE ASSESSMENT

Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

A. Rub the client's feet briskly for several minutes.
B. Obtain a pair of slipper socks for the client.
C. Increase the client's oral fluid intake.
D. Place a moist heating pad under the client's feet.

B. Obtain a pair of slipper socks for the client.

Rationale:
Slipper socks with nonskid soles will help provide warmth and increase the client's level of comfort.

77

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is reinforcing teaching for a client who has a new diagnosis of angina pectoris. The nurse should remind the client of which of the following information about anginal pain?

A. The pain usually lasts more than 20 min.
B. The pain often radiates to the jaw or the back.
C. The pain persists with rest and organic nitrates.
D. The exertion and anxiety can trigger the pain.

D. The exertion and anxiety can trigger the pain.

Rationale:
Exertion and anxiety can trigger the pain of angina, unless it is a variant angina, which occurs at rest.

78

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is reinforcing teaching for a client who is taking warfarin (Coumadin) about monitoring its therapeutic effect. The nurse should explain that the provider will use international normalized ratio (INR) because

A. it also helps with adjusting heparin therapy, should the provider switch the client's medication.
B. It is the only test available for anticoagulant therapy monitoring.
C. the client will only need the test twice per month.
D. It is standardized, so it eliminates the variations different laboratories report in prothrombin time.

D. It is standardized, so it eliminates the variations different laboratories report in prothrombin time.

Rationale:
The INR is a standardized test, which means that the result will be the same, not matter which laboratory performs it. The INR monitors warfarin (Coumadin) therapy, not heparin therapy. The activated partial thromboplastin time (aPTT) monitors heparin therapy.

79

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse in a clinic is caring for a client who has recently begun taking warfarin (Coumadin) and the nurse is reviewing potential drug and food interaction risks. The client should be instructed to avoid which of the following?

A. Cabbage
B. Cantaloupe
C. Green beans
D. White beans

A. Cabbage

Rationale:
Cabbage is a green leafy vegetable and rich in vitamin K. It should be avoided when taking warfarin.

80

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is reinforcing teaching for a client discharged from the hospital after treatment for poor circulation i the lower extremities. Which of the following statements by the client indicates a need for further teaching?

A. "I will avoid crossing my legs at the knees."
B. "I will use a thermometer to check the temperature of my bath water."
C. "I will wear shoes instead of sandals."
D. "I will wear stockings with elastic tops."

D. "I will wear stockings with elastic tops."

Rationale:
Elastic tops on stockings further impair circulation and should b avoided by clients with circulation problems.

81

ATI - TEST 4 PRACTICE ASSESSMENT

A client who is taking medications to treat hypertension has a potassium level of 6.8 mEq/L. Besides notifying the provider, which of the following actions should the nurse take?

A. Suggest that the client use a salt substitute.
B. Obtain a 12-lead ECG.
C. Advise the client to add citrus juices and bananas to her diet.
D. Obtain a blood sample for a serum sodium level.

B. Obtain a 12-lead ECG.

Rationale:
This client's K+ level is elevated. Because hyperkalemia can cause ECG changes, including ventricular dysrhythmias and cardiac arrest, it is essential to obtain a 12-lead ECG and to monitor for such changes.

82

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is reinforcing teaching with a client who has angina pectoris about starting therapy with nitroglycerin (Nitrostat). The nurse should remind to take the medication

A. after each meal and at bedtime.
B. q15 min during an acute attack.
C. at first indication of chest pain.
D. with 8 oz of water.

C. at first indication of chest pain.

Rationale:
The client should take nitroglycerin as soon as he feels pain, pressure, or tightness in his chest and, not wait until the chest pain is severe.

83

ATI - TEST 4 PRACTICE ASSESSMENT

When collecting data from a client who has atrial fibrillation, the nurse would expect his pulse to be

A. slow.
B. not palpable.
C. Irregular.
D. bounding.

C. Irregular.

Rationale:
With atrial fibrillation, multiple ectopic foci stimulate the atria to contract. The AV node is unable to transmit all of these impulses to the ventricles, resulting in a pattern of highly irregular ventricular contractions and thus an irregular pulse.

84

ATI - TEST 4 PRACTICE ASSESSMENT

The nurse is caring for a client receiving nifedipine (Procardia). When the nurse checks the client's BP prior to administering the medication, it is 98/58. Which of the following actions should the nurse take first?

A. Recheck the client's blood pressure.
B. Notify the charge nurse of the result.
C. Document the blood pressure.
D. Take the apical pulse.

A. Recheck the client's blood pressure.

Rationale:
A BP of 98/58 is too low to permit administration of nifedipine. Therefore, the nurse must recheck the BP before taking any further action.

85

ATI - TEST 4 PRACTICE ASSESSMENT

The nurse collecting data from a client who has left-sided heart failure. Which of the following findings should the nurse expect?

A. Jugular venous distention
B. Right upper quadrant pain
C. Pitting edema of the lower legs
D. SOB while lying down

D. SOB while lying down

Rationale:
Orthopnea, or SOB when the client lies down, is a characteristic manifestation of left-sided heart failure. Increased lung pressures from interstitial and alveolar edema causes it.

86

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is caring for a child with Kawasaki disease. Which of the following is the primary system involved with this diagnosis?

A. Cardiovascular
B. Gastrointestinal
C. Integumentary
D. Respiratory

A. Cardiovascular

Rationale:
Cardiovascular changes occur in children diagnosed with Kawasaki disease due to inflammation of the arterioles, venules, and capillaries; therefore, this is the primary system involved with this diagnosis.

87

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is talking with a client who is about to start taking nitroglycerin oral, sustained-released capsules (Nitro-Time). Which of the following instructions should the nurse include?

A. Take one capsule at the onset of anginal pain.
B. Stop taking the medication if side effects are troublesome.
C. Take the medication with meals.
D. Swallow the capsules whole.

D. Swallow the capsules whole.

Rationale:
The client should swallow the capsules whole and not chew or crush them or place them under the tongue.

88

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse on a medical unit is caring for a client who has infective endocarditis. The nurse should observe this client for manifestations of a common complication of this disorder by monitoring for

A. a heart murmur
B. dyspnea
C. fever
D. petechiae

B. dyspnea

Rationale:
Emboli are the major problem; those arising in the right heart chambers will terminate in the lungs, causing dyspnea, and left-chamber emboli may travel anywhere in the arteries, reaching the spleen, kidneys, brain, lungs, or extremities. Fever is a manifestation of infective endocarditis, not of its complications.

89

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is caring for a client who has a blood pressure of 156/98. Which of the following findings would the client manifest with Stage 1 hypertension?

A. Vertigo
B. Uremia
C. Blurred vision
D. Dyspnea

A. Vertigo

Rationale:
The client may manifest blurred vision with malignant hypertensive.

90

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is caring for a client who has thrombophlebitis and has been placed on IV heparin. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses by teh nurse is appropriate?

A. "It usually takes at least two to three days for heparin to dissolve a clot."
B. "The time it takes heparin to dissolve clots varies between clots."
C. "Heparin prevents new clots from forming rather than dissolving established clots."
D. "The time it takes for heparin to dissolve a clot depends on the size of the clot."

C. "Heparin prevents new clots from forming rather than dissolving established clots."

Rationale:
Heparin is given to prevent the formation of new clots by blocking the conversion of prothrombin to thrombin and fibrinogen to fibrin. It does not dissolve established clots.

91

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is preparing to administer digoxin (Lanoxin) to a client who has heart failure. Which of the following actions is appropriate?

A. Withholding the medication if the heart rate is above 100/min
B. Instructing the client to eat foods that are low in potassium.
C. Measure apical pulse rate for 30 seconds before administration.
D. Evaluating the client for nausea, vomiting, and anorexia.

D. Evaluating the client for nausea, vomiting, and anorexia.

Rationale:
Loss of appetite, nausea, vomiting, and blurred or yellow vision may be signs of digoxin toxicity.

92

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is caring for a client with infective endocarditis. Which of the following is a priority manifestation the nurse should monitor for?

A. Anorexia
B. Dyspnea
C. Fever
D. Malaise

B. Dyspnea

Rationale:
When using the ABC approach to client care, the nurse determines the priority manifestation to monitor for is dyspnea. Dyspnea can be an indication of left-sided heart failure, or a pulmonary infarction due to embolization. Fever is a manifestation associated with infective endocarditis, but another manifestation is a greater risk to the client, and therefore a higher priority for the nurse to monitor for.

93

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is preparing to administer heparin intravenously to a client. Which of the following is an appropriate nursing action?

A. Obtain an infusion pump to regulate the continuous flow of the medication.
B. Verify that a dose of vitamin K is available as an antidote.
C. Insert an indwelling catheter to closely monitor the client's urine output
D. Schedule the client's prothrombin time (PT) to be drawn at regular intervals.

A. Obtain an infusion pump to regulate the continuous flow of the medication.

Rationale:
Because of the risk for bleeding, an infusion pump must be used to prevent overdosage and its rate checked q30 to 60 min. The activated partial thromboplastin time (aPTT), not the PT is measured to determine the effectiveness of a heparin drip.

94

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is reinforcing teaching to a group of premenopausal women about activities to reduce the risk of developing coronary artery disease. Which of the following statements by a client requires clarification?

A. "A weight loss program can increase the LDL cholesterol levels."
B. "Exercising regularly will lower HDL cholesterol levels."
C. "Adding foods containing omega-3 fatty acids to my diet can lower my risk."
D. "Increasing the intake of foods containing trans-fatty acids in my diet can lower my risk."

D. "Increasing the intake of foods containing trans-fatty acids in my diet can lower my risk."

Rationale:
Increasing dietary intake of trans fatty acids increases the risk of developing coronary artery disease.

95

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is reinforcing discharge instructions for a client who developed DVT postoperatively and receives anticoagulant therapy. Which of the following instructions should the nurse include?

A. Applying cool compress to her legs.
B. Wearing loose, non-constricting stockings.
C. Flexing her knees and feet frequently.
D. Taking an NSAID tablet daily.

C. Flexing her knees and feet frequently.

Rationale:
Leg, ankle, and foot exercises can help improve circulation and prevent venous stasis while the client is resting. The client should not take any NSAIDs because they can potentiate the action of the anticoagulant and put her at risk for bleeding.

96

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is caring for a client who is prescribed aspirin (Ecotrin) 325 mg and has a history of a previous MI. The nurse instructs the client that the aspirin is prescribed once daily due to its action as an

A. analgesic.
B. anti-inflammatory
C. antiplatelet aggregate
D. antipyretic

C. antiplatelet aggregate

97

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is caring for a client who receives digoxin (Lanoxin). Before administering this medicaiton, which of the following actions should the nurse take?

A. Offer the client a light snack.
B. Measure the client's BP.
C. Measure the client's apical pulse.
D. Weight the client.

C. Measure the client's apical pulse.

98

ATI - TEST 4 PRACTICE ASSESSMENT

A nurse is assisting with the care of an older adult client who has had a cardiac catheterization. Which nursing interventions should the nurse contribute to the client's plan of care for the next 8 hr? (Select all that apply)

A. Check peripheral pulse in the affected extremity.
B. Place the client in high Fowler's position.
C. Measure the client's vital signs q4h.
D. Keep the client's hip and leg extended.
E. Have the client remain in bed up to 6 hr.

A. Check peripheral pulse in the affected extremity.
D. Keep the client's hip and leg extended.
E. Have the client remain in bed up to 6 hr.

Rationale:
Measure the client's vital signs q4h is incorrect. The nurse should measure the client's VS q15 min for the first hr and q30 min for 2 hr or until stable, then q4h after that.