Description
35.A nurse is assessing a client who has nephrotic syndrome. Which of the findings should the nurse expect?
A.Proteinuria
B.Flank pain
C.Hyperalbuminemia
D.Hypotension
Rationale: Lewis book page 1075. Clinical manifestation of N.S.: peripheral edema, massive proteinuria, HTN,
hyperlipidemia, and hypoalbuminemia.
36.A nurse is assessing a client who has right-sided heart failure. Which of the following assessment findings
should the nurse expect to find?
a. Oliguria (Left)
b. S3/S4 galloping heart sounds (Left)
c. Poor skin turgor
d. Pitting edema
Rationale: Page 198 Chapter 32 of ATI Book.
37.A nurse is caring for a client who has newly inserted chest tube. The nurse should clarify which of the
following prescriptions with the provider?
A.Notify the provider when tidaling ceases. (Yes notify)
B.Assisting the client out of bed three times daily.
C.Vigorously strip the chest tube twice daily. (VIGOROUSLY and TWICE A DAY)
D.Administer morphine 2 mg IV bolus every 3 hr PRN for pain. (Don’t need to clarify)
Rationale: Page 104 chapter 18 of ATI Book it says that: “Do not strip or milk tubing; only perform when
prescribed. Stripping creates a high negative pressure and can damage lung tissue.”
38.A nurse is teaching a client who is taking an ACE inhibitor for heart failure. Which of the following instructions
should the nurse include for home management of heart failure?
A,Obtain daily weight.
B.Use of salt substitute. (Avoid it)
C.Monitor I and O.
D.Limit daily activity.
Rationale: Pg 199 ATI
Book.
39.A nurse is providing discharge teaching to a client who has a permanent pacemaker. Which of the following
statements by the client indicates an understand of the teaching?
A.I need to maintain pressure over the pacemaker site with an elastic bandage.
B.I need to check my pulse rate every day for a full minute.
C.The pacemaker will deliver shock if I develop a dysrhythmia
D.When a microwave oven is in use, I need to stay out of the room.
Rationale: Chapter 29 pg 177 of ATI book.
40.A nurse in a clinic is providing preventive teaching to an older adult client during well visit. The nurse should
instruct the client that which of the following immunization are recommended for healthy adults after age 60?
SATA.
A.Herpes Zoster
B.Influenza
C.HPV
D.Meningococcal
E.Pneumococcal Polysaccharide
41.A nurse is assessing a client who is 4hr postoperative following arterial revascularization of the left femoral
artery. Which of the following findings should the nurse report immediately?
A.Bruising around the incision site
B.Pallor in the affected extremity
C.Urine output 150mL over 4hr
D.Temperature of 37.9 (100.2)
Rationale: Chapter 35 pg 217.
42.A nurse is caring for an older adult client who has not been eating. Which of the following findings indicates
dehydration?
A.Crackles auscultated bilaterally (S/sx suggestive of fluid overload)
B.Capillary refill of 2 seconds (Brisk; normal)