DETAILED SOLUTIONS FOR BEST SCORES WITH RATIONALES.

1.A nurse is assessing a client who is 12hr postoperative following a colon resection. Which of the following

findings should the nurse report to the surgeon?

1. Heart rate 90/min

2. Absent bowel sounds → normal findings after major bowel surgery; takes several days to return to

normal.

3. Hgb 8.2 g/dl

4. Gastric pH of 3.0

Rationale: Normal Hgb is 13-18M g/dl, 12-16 g/dl. This may indicate a possible hemorrhaging.

2. A nurse is caring for a client who has diabetes insipidus. Which of the following medications should the

nurse plan to administer?

a. Desmopressin

b. Regular insulin

c. Furosemide

d. Lithium carbonate

Rationale: Diabetes Insipidus has decreased ADH. Administer Desmopressin/Vasopressin increase ADH and keeps

pt. on urinating

3. A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily for 3

years. Which of the following test should the nurse monitor?

a. Fasting blood glucose

b. Stool for occult blood

c. Urine for white blood cells

d. Serum calcium

Rationale:ATI Pharm 16. Pg. 485 Ibuprofen (NSAIDs) monitor for GI bleed (bloody, tarry stools, abd pain).

4. A nurse in the emergency department is assessing a client. Which of the following actions should the nurse

take first (Click on the “Exhibit” button for additional information about the client. There are three tabs that

contain separate categories of data.)

a. Obtain a sputum sample for culture

b. Prepare the client for a chest x-ray

c. Initiate airborne precautions

d. Administer ondansertron.

Rationale: No idea what the Exhibit is all about; wont be able to answer it.

5. A nurse is contacting the provider for a client who has cancer and is experiencing breakthrough pain.

Which of the following prescriptions should the nurse anticipate?

a. Transmucosal fentanyl

b. Intramuscular meperidine

c. Oral acetaminophen

d. Intravenous dexamethasone

Rationale:ATI pg. 27

6. A nurse is admitting a client who reports chest pain and has been placed on a telemetry monitor. Which of

the following should the nurse analyze to determine whether the client is experiencing a myocardial

infarction?

a. PR interval

b. QRS duration

c. T wave

d. ST segment

Rationale: ST elevation indicates MI. ST depression indicates ischemia

7. A nurse is teaching a client who has ovarian cancer about skin care following radiation treatment. Which of

the following instructions should the nurse include?

a. Pat the skin on the radiation site to dry it