ATI NU 160 Exam 1 Spring 2025

Correct Answer: D. Symptoms of visual disturbance

Explanation

Visual disturbances (e.g., yellow-green halos, blurred vision, or seeing bright spots) are signs of digoxin toxicity. Digoxin (a cardiac glycoside) is used to improve heart contractility in heart failure, but it has a narrow therapeutic index. Other signs of toxicity include:

Nausea, vomiting, diarrhea

Bradycardia

Confusion, dizziness

Patients should report any visual changes immediately.

Explanation of Incorrect Answers:

A. Monitor weight daily 

While daily weight monitoring is crucial for heart failure patients to track fluid retention, this is not specific to digoxin. A sudden weight gain (e.g., >2–3 lbs in 24 hours) signals worsening heart failure, not digoxin toxicity.

B. Hold if HR is less than 70 

Digoxin should be held if HR is less than 60 bpm, not 70. Patients should check their pulse before taking digoxin and notify their provider if it is <60 bpm.

C. Abdominal pain is a normal side effect 

Abdominal pain is NOT a normal side effect and could be a sign of digoxin toxicity. Nausea, vomiting, and abdominal pain can indicate early toxicity

Summary:

Visual disturbances (D) are a key sign of digoxin toxicity and should be reported immediately. Monitoring weight daily (A) is important for heart failure but not digoxin-specific. The correct HR threshold for holding digoxin is <60 bpm, not 70 (B). Abdominal pain (C) is a warning sign of toxicity, not a normal side effect.

Correct Answer: Assess pulses in the client's affected arm

Explanation:

After a left-sided cardiac catheterization with an upper extremity insertion site, the priority nursing action is to assess the pulses in the affected arm to evaluate for circulatory complications, such as arterial occlusion or reduced perfusion. This ensures that blood flow is not compromised due to potential thrombus formation or vascular injury at the insertion site.

Why the Other Options Are Incorrect:

Keep the client NPO for at least 2 hr following the procedure – This is not necessary after a cardiac catheterization. The client may resume eating and drinking once they are stable and awake, unless contraindicated.

Encourage the client to ambulate within 30 min following the procedure – Early ambulation is not advised immediately after a cardiac catheterization, as movement can increase the risk of bleeding or hematoma formation at the insertion site. The timing of ambulation depends on the specific access site and hospital protocol but typically requires a period of immobilization.

Apply light pressure to the insertion site – If bleeding occurs, firm pressure (not light pressure) is required to control it. However, prophylactic pressure is not needed unless active bleeding is observed. Most facilities use a compression device or bandage to secure hemostasis.

Summary:

​​​​​​​The most important assessment after a left-sided cardiac catheterization via the upper extremity is to check pulses in the affected arm to detect circulatory compromise or complications early.

Correct Answer: Encourage the client to walk.

Explanation:

For a client with deep-vein thrombosis (DVT) receiving anticoagulation therapy, encouraging ambulation is essential as it promotes circulation and prevents further clot formation. Walking helps reduce venous stasis and supports the body's natural ability to break down the clot over time.

Why the Other Options Are Incorrect:

Apply cold compresses to the affected extremity –

Cold compresses are not recommended for DVT because they cause vasoconstriction, which may worsen circulation and increase clot formation. Warm compresses are sometimes used to alleviate discomfort but are not the primary intervention.

Massage the affected extremity gently 

Massaging the affected limb is contraindicated because it can dislodge the clot, increasing the risk of a pulmonary embolism, which is a life-threatening complication.

Apply compression stockings at bedtime 

Compression stockings should be applied in the morning before getting out of bed when the legs are least swollen, not at bedtime. This helps prevent blood pooling and reduces swelling.

Summary:

For a client with DVT on anticoagulation therapy, encouraging ambulation is the best intervention as it promotes circulation and prevents complications. Applying cold compresses, massaging the extremity, or using compression stockings at bedtime are either ineffective or potentially harmful.

Correct Answer: B. Administer antibiotics to the client.

Explanation:

Osteomyelitis is a serious bone infection that requires immediate antibiotic therapy to prevent sepsis, bone necrosis, and further complications. The priority intervention is administering IV antibiotics as prescribed to eliminate the infection as quickly as possible.

Why the Other Options Are Incorrect:

A. Provide the client with antipyretic therapy.

Incorrect because while fever is common in osteomyelitis, treating the underlying infection (with antibiotics) is the priority. Antipyretics like acetaminophen may help with symptoms, but they do not treat the root cause of the infection.

C. Increase the client’s protein intake.

Incorrect because adequate nutrition, including protein, supports healing, but it is not the priority in the acute phase. The infection must be controlled first.

D. Teach relaxation breathing to reduce the client’s pain.

Incorrect because pain management is important, but controlling the infection with antibiotics is the top priority. If the infection persists, pain will continue despite relaxation techniques.

Summary:

The correct answer is B, as administering antibiotics is the most urgent intervention to stop the infection and prevent further complications. The other interventions may be helpful but are not as critical in the acute phase.

Correct Answer:  Leaning in, facing the patient.

Explanation:

Active listening involves attentive body language, eye contact, and gestures that demonstrate engagement and understanding with the patient. Leaning in and facing the patient signals attentiveness, encourages communication, and fosters a therapeutic nurse-patient relationship.

Incorrect Answers & Rationale:

"Taking frequent notes."

Incorrect because while note-taking is sometimes necessary, excessive note-taking can distract from eye contact and hinder active engagement. Active listening requires focusing on the patient’s verbal and nonverbal cues rather than being preoccupied with documentation.

"Sitting with legs crossed."

Incorrect because crossing legs may indicate a closed-off posture and could make the patient feel less comfortable sharing personal information. Open body language, such as uncrossed legs and arms, is more welcoming and encouraging.

"Checking the clock frequently."

Incorrect because looking at the clock or watch may convey disinterest, impatience, or lack of concern for the patient’s needs. Active listening requires giving the patient undivided attention and being fully present during the interaction.

Summary:

Active listening behaviors include leaning in, facing the patient, nodding, and maintaining eye contact. These actions show genuine interest, support, and attentiveness, which are essential for effective nurse-patient communication.

Correct Answers:

Have the client remain in bed up to 6 hours.

Keep the client’s hip and leg extended.

Check peripheral pulses in the affected extremity.

Explanation of Correct Answers:

Have the client remain in bed up to 6 hours

After a cardiac catheterization, especially with a femoral artery approach, the client must stay on bed rest to prevent bleeding or hematoma formation at the insertion site. The duration of bed rest varies but is typically between 2 to 6 hours, depending on the type of closure device used.

Keep the client’s hip and leg extended

If the catheterization was performed through the femoral artery, the hip and leg on the affected side must remain extended to prevent pressure on the insertion site. Bending the hip or leg can lead to bleeding or arterial occlusion.

Check peripheral pulses in the affected extremity

After the procedure, circulation in the limb distal to the insertion site must be frequently assessed. This helps detect complications such as arterial occlusion, thrombosis, or hematoma formation. Peripheral pulse checks include assessing pedal pulses, capillary refill, skin temperature, and color.

Explanation of Incorrect Answers:

Measure the client’s vital signs every 4 hours

This is incorrect because vital signs must be monitored more frequently immediately after the procedure. The recommended schedule is every 15 minutes for the first hour, every 30 minutes for the next hour, then every hour for several hours before transitioning to routine checks.

Place the client in high-Fowler’s position

This is incorrect because sitting the client upright at 60 to 90 degrees can increase the risk of bleeding at the catheter insertion site. The client should instead remain supine or have the head of the bed elevated no more than 30 degrees to minimize pressure on the artery.

Summary:

After a cardiac catheterization, the nurse must focus on preventing bleeding and monitoring circulation. This includes keeping the client on bed rest, ensuring the affected limb remains extended, and frequently checking peripheral pulses. Vital signs should be monitored closely in the first few hours, and the client should not be placed in a high-Fowler’s position to avoid unnecessary pressure on the insertion site.

Correct Answer:   To provide support for the client and family in coping with terminal illness.

Explanation:

Hospice care is focused on providing comfort, emotional support, and symptom management for terminally ill clients and their families. The primary goal of hospice is to help improve quality of life, relieve pain and distressing symptoms, and provide psychological and spiritual support for both the client and family as they navigate the end-of-life process. Unlike curative treatments, hospice care does not aim to prolong life or cure the disease but ensures a dignified and comfortable transition.

Why the Other Options Are Incorrect:

To help the client find appropriate treatment options.

Hospice care is for clients with terminal illnesses who have decided to stop curative treatment. The focus is on comfort, not finding new treatment options.

 To ensure that the client gets counseling regarding health care costs.

While financial concerns may be addressed as part of hospice services, this is not the primary goal of a hospice referral. The main goal is support and symptom management, not financial planning.

To teach the client and family about cancer and its treatment.

Cancer education is more relevant in early treatment stages. By the time a patient is referred to hospice, they have already made decisions regarding their treatment goals, focusing on comfort rather than further education about the disease itself.

Summary:

The main goal of a hospice referral is to provide physical, emotional, and spiritual support for the client and their family as they cope with the challenges of terminal illness. The focus is on comfort and quality of life rather than curative treatment.

Correct Answers:

A: "I must stop smoking."

D: "I need to monitor my weight."

E. "I am limiting my intake of fast foods."

Explanation:

Coronary artery disease is caused by a buildup of plaque in the arteries, leading to reduced blood flow to the heart. Major risk factors include smoking, poor diet, obesity, lack of exercise, excessive alcohol intake, and high blood pressure. The correct responses reflect actions that help reduce these risks.

A. "I must stop smoking." This is correct because smoking damages blood vessels, increases blood pressure, and raises cholesterol levels. Quitting smoking significantly lowers the risk of heart disease.

D. "I need to monitor my weight." This is correct because maintaining a healthy weight reduces strain on the heart and lowers the risk of conditions such as high blood pressure and diabetes, both of which contribute to coronary artery disease.

E. "I am limiting my intake of fast foods." This is correct because fast foods are often high in unhealthy fats, sodium, and refined carbohydrates, which contribute to obesity, high cholesterol, and high blood pressure, all of which are risk factors for coronary artery disease.

Why The Other Options Are Incorrect

B. "I should limit my exercise." This is incorrect because regular exercise improves heart health. The client should engage in at least 150 minutes of moderate-intensity exercise per week to strengthen the heart and reduce the risk of coronary artery disease.

C. "I will stop consuming alcohol." This is incorrect because moderate alcohol intake does not necessarily increase heart disease risk. However, excessive alcohol use raises blood pressure and contributes to obesity, which are risk factors for coronary artery disease.

Summary:

The correct answers are A, D, and E because quitting smoking, maintaining a healthy weight, and reducing fast food intake help lower the risk of coronary artery disease. The other options are incorrect because regular exercise is beneficial, and moderate alcohol intake does not necessarily increase the risk.

Correct Answer: C. Radial pulse in the left arm.

Explanation:

Since the left antecubital (inner elbow) area was used as the insertion site for the cardiac catheterization, the nurse should assess distal circulation in the same extremity to ensure adequate blood flow. The radial pulse in the left arm is the best choice because it is located downstream from the insertion site and will indicate if there is any arterial compromise, such as clot formation or occlusion.

Why the Other Options Are Incorrect:

A. Brachial pulse in the left arm

The brachial pulse is proximal (closer to the heart) to the insertion site. It would not effectively assess for distal circulation issues that could result from arterial damage.

B. Brachial pulse in the right arm

This pulse is in the opposite arm and does not provide information about circulation in the affected limb

D. Radial pulse in the right arm

The radial pulse in the right arm does not assess blood flow in the left arm, where the catheter was inserted. Checking the unaffected limb does not help evaluate for complications like ischemia or clotting in the left arm.

Summary:

The correct answer is C, as checking the radial pulse in the left arm helps evaluate distal circulation and detect any complications related to the catheterization. The other options do not adequately assess perfusion in the affected limb.