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ATI MED SURG PRACTICE B - WITH
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A nurse is providing teaching to a client who has AIDS. Which of the following statement by the client indicates an understanding of the teaching? a. "I should clean my toothbrush in the dishwasher once a month." b. "I should eat more fresh fruit and vegetables." c. "I will avoid drinking a glass of cold liquid that has been standing for 30 minutes." d. "I will take my temperature once a day." d. "I will take my temperature once a day." A nurse is providing teaching to a client who has asthma about the use of a metered- dose inhaler. The nurse should identify that which of the following client actions indicates an understanding of the teaching? a. Breathing in rapidly while administering the medication b. Washing the plastic case and cap of the inhaler in the dishwasher c. Holding breath for 10 seconds after inhaling d. Waiting 15 seconds between puffs, if two puffs are required c. Holding breath for 10 seconds after inhaling A nurse is reviewing the lab findings of a client who developed chest pain 6 hr ago. The nurse should identify which of the following findings as an indication of a MI? a. Creatine kinase (CK-MB) 85 units/L b. High-density lipoprotein (HDL) 65 mg/dL c. Alanine aminotransferase (ALT) 28 units/L d. Troponin I 8 ng/mL d. Troponin I 8 ng/mL
A nurse is caring for a client who had a nephrostomy tube inserted 12 hr ago. Which of the following findings should the nurse report to the provider? a. The client's urinary output has increased. b. The client reports back pain. c. The client's urine color is red tinged. d. The client's BUN is 18 mg/dL. b. The client reports back pain. A nurse is providing discharge teaching about infection prevention to a client who has AIDS. Which of the following statements by the client indicates understanding of the teaching? a. "I will eat a salad at least once each day to increase my intake of vitamin K." b. "I can work in my flower garden as long as I wear gardening gloves to cover my skin." c. "I will no longer floss my teeth after brushing my teeth." d. "I can sip on a glass of juice for at least 2 hours before I should discard it." c. "I will no longer floss my teeth after brushing my teeth." A nurse is providing discharge teaching to a client who is postop following a modified radical mastectomy. Which of the following instructions should the nurse include? a. Flex the affected arm when ambulating. b. Numbness can occur along the inside of the affected arm. c. Begin active range-of-motion exercises 1 day after surgery. d. Dress in clothing that fits snugly. b. Numbness can occur along the inside of the affected arm. A nurse is providing postop teaching for a client who had a total knee arthroplasty. Which if the following instruction should the nurse include? a. Flex the foot every hour when awake.
a. Constipation b. Insomnia c. Tachycardia d. Diaphoresis a. Constipation A nurse is caring for a client who has terminal cancer. The client tells thenurse, "I wish I could stop these treatments. I am ready to die." Which of the following statements should the nurse make? a. "Discontinuing with the treatments is your choice if it is your wish to do so." b. "Your daughter is named as your health care surrogate. I will ask her if you can stop them." c. "I will call your spiritual advisor to come in, so you can discuss this with them." d. "Next time you have an oncology appointment, you should ask the oncologist." a. "Discontinuing with the treatments is your choice if it is your wish to do so." A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After ensuring a patent airway, which of the following nursing interventions is the priority? a. Applying oxygen via face mask b. Placing the client in Fowler's position c. Administering epinephrine d. Initiating an IV infusion of 0.9% sodium chloride a. Applying oxygen via face mask
A nurse is reviewing the medical record of a client who is taking warfarin for chronic A. Fib. Which of the values should the nurse identify as a desired outcome for this therapy a. INR 1 b. INR 2. c. aPTT 45 seconds d. aPTT 90 seconds b. INR 2. A nurse is teaching a client about the use of TENS for the management of bone cancer pain. The nurse should explain that applying a TENS unit to the painful area has which of the following effects? a. Electrically generated feelings of heat b. Cryotherapy for painful areas c. A tingling sensation replacing the pain d. Realignment of energy flow through meridians c. A tingling sensation replacing the pain A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect? a. Low urine specific gravity b. Hypertension c. Bounding peripheral pulses
a. Warm, moist skin b. Distended neck veins c. Dark amber, odiferous urine d. Orthostatic hypotension b. Distended neck veins A nurse on a medsurg unit is reviewing the medical record of an older adult client who is receiving IV fluid therapy. Which of the following client information should indicate to the nurse that the client requires re-evaluation of the IV therapy prescription? Exhibit 1: Temperature 37.1° C (98.8° F) Heart rate 88/min Respiratory rate 18/min Blood pressure 118/ O2 saturation 96% Pain rating (0 to 10) 0 Exhibit 2: Propranolol 40 mg PO BID Metformin 500 mg PO BID Alendronate sodium 10 mg PO daily Exhibit 3: Hgb 15.1 g/dL Hct 54.2% BUN 29 mg/dL Sodium 145 mEq/L Potassium 4.7 mEq/L
a. Blood pressure b. Prescribed medications c. Oxygen saturation d. BUN d. BUN Hct and BUN indicate dehydration and IV fluids need to be increased A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of the following findings should the nurse identify as a manifestation of the condition? a. Bounding pedal pulse b. Capillary refill less than 2 seconds c. Pain that increases with passive movement d. Areas of warmth on the cast c. Pain that increases with passive movement A nurse is providing teaching to a client who takes ginkgo biloba as an herbal supplement. Which of the following statements should the nurse make? a. "Ginkgo biloba relieves nausea for people who have vertigo." b. "Taking ginkgo biloba will help relieve your joint pain." c. "Ginkgo biloba can cause an increased risk for bleeding." d. "Taking ginkgo biloba decreases the risk of migraine headache." c. "Ginkgo biloba can cause an increased risk for bleeding."
d. Remove soiled linens from the client's room each day. a. Keep a lead-lined container in the client's room. A nurse is caring for a client who is 4 hr postop following an open reduction internal fixation of the right ankle. Which of the following assessment findings should the nurse report to the provider? a. Extremity cool upon palpation b. Serosanguineous drainage on the dressing c. Capillary refill of 2 seconds d. Client report of discomfort when moving toes a. Extremity cool upon palpation A nurse is reviewing the medical record of a client who has SLE. Which of the following findings should the nurse expect? a. Facial butterfly rash b. Bradycardia c. Esophagitis d. Interstitial fibrosis a. Facial butterfly rash A nurse is providing teaching to a client who has end-stage kidney disease and is waiting for a kidney transplant. Which of the following information should the nurse provide?
a. Kidney donation must come from a living donor. b. Immunosuppressive therapy is necessary until the donated kidney begins producing urine. c. Hemodialysis is sometimes required following surgery. d. Kidney transplant recipients can resume their regular diet following surgery. c. Hemodialysis is sometimes required following surgery. A home health nurse is providing teaching to a client who has stage 1 pressure injury on the greater trochanter of his left hip. Which of the following instructions should the nurse include in the teaching? a. Clean the wound daily with an antiseptic. b. Use a donut-shaped pillow when sitting in a chair. c. Change position every hour. d. Massage the area two times daily. c. Change position every hour. A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following information should the nurse include in the teaching a. "Take this medication on an empty stomach." b. "Eczema is an immediate expected adverse effect of this medication." c. "Increase fiber intake to avoid constipation." d. "Monitor your blood pressure monthly." c. "Increase fiber intake to avoid constipation."
d. Dysphagia a. Dyspnea A nurse is administered packed RBCs to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction? a. Anorexia and jaundice b. Bronchospasm and urticaria c. Hypertension and bounding pulse d. Low back pain and apprehension d. Low back pain and apprehension A nurse is planning care for a client who is postop following a laparotomy and has a closed-suction drain. Which of the following actions should the nurse take to manage the drain? a. Set the wall suction to 80 to 100 mm Hg. b. Compress the drain reservoir after emptying. c. Allow the drainage to collect on a sterile gauze dressing. d. Position the drain below the bed to promote drainage. b. Compress the drain reservoir after emptying. A nurse is providing discharge instructions to a client who has laryngeal cancer and is receiving radiation therapy. Which of the following statements by the client indicates an understanding of the teaching?
a. "I will wear a badge to measure how much radiation I am receiving." b. "I will remove the markings on my skin after each radiation treatment." c. "I will avoid direct exposure to the sun." d. "I will rinse my mouth with a commercial mouthwash." c. "I will avoid direct exposure to the sun." A nurse is caring for a client who has DKA. Which of the following findings should indicate to the nurse that the client's condition is improving? a. Potassium 3.5 mEq/L b. pH 7. c. Glucose 272 mg/dL d. HCO3- 14 mEq/L c. Glucose 272 mg/dL A nurse is assessing a client while suctioning the client's tracheostomy tube. Which of the following findings should indicate to the nurse the client is experiencing hypoxia? a. The client starts to cough. b. The client's heart rate increases. c. The client is diaphoretic. d. The client's blood pressure decreases. b. The client's heart rate increases.
b. 1 ampule of 50% dextrose IV bolus c. NPH insulin 60 units subcutaneous d. Regular insulin 20 units IV bolus d. Regular insulin 20 units IV bolus A nurse is evaluating the plan of care for 4 clients after 2 days of hospitalization. The nurse should identify the need to revise the plan for which of the following clients? a. A client who is taking potassium supplements, has a potassium level of 3.2 mEq/L, and reports constipation b. A client who has Alzheimer's Disease (AD), has a room near the nurse's station, and is agitated c. A client who is postoperative following abdominal surgery and reports feeling that something "popped" when they coughed d. A client who has a conductive hearing loss, speaks softly, and is scheduled for a cerumen removal c. A client who is postoperative following abdominal surgery and reports feeling that something "popped" when they coughed A nurse is caring for a client who has a positive culture for MRSA. Which of the following actions should the nurse take? a. Obtain a sputum specimen to determine if there is colonization. b. Bathe the client using chlorhexidine solution. c. Place the client in droplet isolation. d. Restrict visits from the client's friends and family. b. Bathe the client using chlorhexidine solution.
A PACU nurse is assessing a client who is postop following a right nephrectomy. The client's initial vital signs were heart rate 80/min, BP 130/70, RR 16/min, and temp 96.8. which of the following vital sign changes should alert the nurse that the client might be hemorrhaging a. Heart rate 110/min b. Blood pressure 160/70 mm Hg c. Respiratory rate 14/min d. Temperature 38.4° C (101.1° F) a. Heart rate 110/min A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of the following findings should the nurse identify as the priority? a. Report of sore throat b. Report of memory loss c. Alopecia d. Mucositis a. Report of sore throat A nurse is assessing a client following the completion of hemodialysis. Which of the following findings is the nurse's priority to report to the provider? a. Temperature 37.2° C (99° F) b. Blood pressure 100/70 mm Hg c. Weight loss
a. "Older adult clients might require up to 6 grams of acetaminophen over 24 hours for effective pain control." b. "Ibuprofen can cause gastrointestinal bleeding in older adult clients." c. "Meperidine is the medication of choice for older adult clients experiencing severe pain." d. "Older adult clients taking oxycodone are at risk for diarrhea." b. "Ibuprofen can cause gastrointestinal bleeding in older adult clients." A nurse is checking the ECG rhythm strip for a client who has temporary pacemaker. The nurse notes a pacemaker artifact followed by a QRS complex. Which of the following actions should the nurse take? a. Document that depolarization has occurred. b. Increase the pacemaker's voltage. c. Decrease the pacemaker's sensitivity. d. Check the placement of the ECG leads. a. Document that depolarization has occurred. A nurse in an emergency department is assessing an older adult client who has a fractured wrist following a fall. During the assessment, the client states, "Last week I crashed my car because my vision suddenly became blurry."." Which of the following actions is the nurse's priority? a. Check the client's neurologic status. b. Document the client's statements. c. Prepare the client for a CT scan. d. Teach the client about using safety precautions for falls. a. Check the client's neurologic status.
A nurse is preparing to administer phenytoin 600 mg PO daily to a client. The amount available is oral solution 125 mg/5mL. how many mL should the nurse administer? 24 mL A nurse is planning care for a client who is postop following a parathyroidectomy. Which of the following actions should the nurse identify as the priority? a. Use pillows to support the client's head and neck. b. Offer opioid medication. c. Place a tracheostomy tray at the bedside. d. Place the client in semi-Fowler's position. c. Place a tracheostomy tray at the bedside. A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following interventions should the nurse include in the plan? a. Encourage the client to take deep breaths after the procedure. b. Assist the client to hold their arms up during the procedure. c. Instruct the client to remain NPO after midnight prior to the procedure. d. Keep the client on bed rest for 8 hr following the procedure. a. Encourage the client to take deep breaths after the procedure.
