ATI FINAL EXAM REVIEW

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1. A nurse is assessing client who have intravenous therapy prescribed. Which assessment finding for a client with a PICC requires immediate attention? a. Upper extremity swelling is noted 2. A nurs... e assesses a client peripheral IV site, notices edema and tenderness above the site. Which action should the nurse take next? a. Stop the infusion of IV fluids 3. The nurse assesses a client who has a severe burn injury. Which statement indicates the client understands the psychosocial impact of a severe burn injury? a. “It is normal to feel some depression” 4. An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough. Which action should the nurse take first? a. Apply oxygen and continuous pulse oximetry. 5. A nurse administers topical gentamicin sulfate (Garamycin) to a client’s burn injury. Which laboratory value should the nurse monitor while the client is prescribed this therapy? a. Creatinine 6. A nurse uses the rule of nines to assess a client with burn injuries to the entire back region and left arm. How should the nurse document the percentage of the client’s body that sustained burns? a. 27% 7. A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the clients face is puffy and the eyelids are swollen. What action by the nurse takes priority? a. Assess the client’s oxygen saturation 8. A UAP was feeding a client with a tracheostomy. Later that evening the UAP reports the client had a coughing spell during the meal. What action by the nurse takes priority? a. Assess the client’s lung sounds 9. A client is receiving oxygen at 4 liters per nasal cannula. What comfort measure may the nurse delegate to a UAP? a. Apply water-soluble ointment to nares and lips. 10. Which teaching point is most important for the patient with a peritonsillar abscess? a. Take all antibiotics as directed 11. A nurse has educated a client on isoniazid. What statement by the client indicates that teaching has been effective? a. “I will take this medication on an empty stomach” 12. A client has been taking isoniazid for tuberculosis for 3 weeks. What laboratory results need to be reported to the primary health care provider immediately? a. Alanine Aminotransferase (ALT): 180u/L 13. An intubated client’s oxygen saturation has dropped to 88%. What action by the nurse takes priority? a. Listen [Show More]

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