ATI Exam 4

A nurse is providing information to a client who has osteoarthritis of the hip and knee. Which of the following information should the nurse include in the information? (Select all that apply.)

A. Apply heat to joints to alleviate pain. C. reduce the amount of exercise done on days with increased pain E. active range of motion is more effective than passive

A nurse is planning care for a client who has acute gastritis. Which of the following nursinginterventions should the nurse include in the plan of care? (Select all that apply.)

A. Evaluate intake and output. B. Monitor laboratory reports of electrolytes.

A nurse is caring for a client who is receiving TPN solution. The current bag of solution was hung 24 hrs ago and 400 mL remains to infuse. Which of the following is the appropriate action for the nurse to take?

A. Remove the current bag and hang a new bag

A nurse is completing nutrition teaching for a client who has pancreatitis. Which of the following statements by the client indicates an understanding of the teaching? SATA

A: " I plan to eat small, frequent meals" B: " I will eat easy-to-digest foods with limited spice" C: " I will use skim milk when cooking"

A nurse is assessing a client who has advanced cirrhosis. The nurse should identify which of the following findings as indicatorsof hepatic encephalopathy? (Select all that apply.)

B. Change in orientation C. Asterixis E. Fetor hepaticus

A nurse is reviewing the serum laboratory data of a client who has an acute exacerbation of Crohn's disease. Which of the following laboratory tests should the nurse expect to be elevated?

B. Erythrocyte sedimentation rate C. WBC

A nurse is completing an assessment of a client who has GERD. Which of the following is an expected finding?

B. painful swallowing

A nurse is completing discharge teaching for a client who has an infection due to Heliobacter pylori (H. pylori). Which of the following statements by the client indicates understanding of the teaching?

C. "I will take a combination of medications for treatment."

A nurse is completing an assessment of a client who has a gastric ulcer. Which of the following findings should the nurse expect? (Select all that apply)

C. Client reports a sensation of bloating D. Client states that pain occurs 30 min to 1 hr after a meal E. Client experiences pain upon palpation of the epigastric region

A nurse is teaching a client who has a new diagnosis of dumping syndrome following a gastric surgery. Which of the following information should the nurse include in the teaching?

D. Increase protein in the diet

A nurse is admitting a client who has bleeding esophageal varices. The nurse should anticipate a prescription for which of the following medications?

D. Vasopressin

A nurse is caring for a client following a paracentesis. Which of the following indicate the bowel was perforated during the procedure?

Temperature elevation

A nurse is assessing an older adult client who has arteriosclerosis and is sched for a poss r lower ext amputation. Which of the following are expected findings in affected extremity? (select all that apply

A skin cool to touch from mid calf to toes C palpable pounding pedal pulse D lack of hair on lower leg

A nurse in a clinic is teachinga client who has ulcerativecolitis. Which of the following statements by the client indicates understanding of the teaching?

"I will plan to limit fiber in my diet."

A nurse is planning care for a client who is postop following an arthroscopy of the knee. Which of the following is an appropriate action by the nurse? (select all that apply)

A assess color and temp of extremity C elevate the extremity D admin opioid meds E assess pulse and sensation in the foot

A nurse is planning discharge teaching for a client who had total hip arthro. Which of the following should the nurse include in the teaching? (select all that apply)

A clean incision daily with soap and water C sit in straight-backed armchair E use raised toilet seat

A nurse is caring for a client following a below the elbow amp. Which of the following are appropriate actions by the nurse? (select all that apply)

A encourage dependent positioning of residual limb B inspect for presence and amt of drainage C implement shrinkage intervention of residual limb E assess for feelings of body image changes

A nurse is presenting info to clients at a health fair on measures to reduce the risk of amputation. Which should the nurse include? (select all that apply)

A encourage smokers to consider cessation B encourage DM pts to maintain glood glucose within normal range C instruct clients to unplug electric equip when performing repairs D encourage those with vasc dz to maintain good foot care

A nurse is completing a preop teaching plan for a client who is to have a total hip arthro. Which of the following should the nurse include in the teaching plan? (select all that apply)

A encouraging complete autologous blood donation D using an abductor pillow when turning E performing isometric exercises

A nurse is caring for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The nurse should anticipate prescriptions for which of the following medications? (Select all that apply)

A. Antacids B. Histamine 2 receptor antagonists E. Proton pump inhibitors

A nurse is caring for a client who has cirrhosis. Which of the following medications can the nurse expect to administer to this client? (Select all that apply.)

A. Diuretic B. Beta‐blocking agent D. Lactulose

A nurse is assessing a client who has osteoarthritis of the knees and fingers. Which of the following clinical manifestations should the nurse expect to find? (Select all that apply.)

A. Heberden's nodes D. Enlarged joint size E. Limp when walking

A nurse is completing preprocedure teaching for a client who will undergo a sigmoidoscopy. Which of the following should the nurse include in the teaching? (Select all that apply)

A. Increased flatulence can occur following the procedure. B. NPO status should be maintained preprocedure.

A nurse is teaching a client who has hepatitis B about home care. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

A. Limit physical activity. B. Avoid alcohol. E. Eat small frequent meals.

A nurse is planning care for a client who has a new prescription for total parenteral nutrition (TPN). Which of the following interventions should be included in the plan of care? (Select all that apply)

A. Obtain a capillary blood glucose four times daily C. Monitor vital signs three times during a 12 hr shift D. Change the TPN IV tubing every 24 hrs.

A nurse in the emergency department is completing an assessment of a client who has suspected stomach perforation due to a peptic ulcer. Which of the following findings should the nurse expect? (Select all that apply)

A. Rigid abdomen B. Tachycardia E. Rebound tenderness

A nurse is teaching a client who has a duodenal ulcer and a new prescription for esomeprazole. Which of the following information should the nurse include in the teaching? (Select all that apply)

A. Take medication 1 hr before a meal B. Limit NSAIDs when taking this medication

A nurse is planning care for a client who is to have an electromyography (EMG). Which of the following should the nurse include in the plan of care? (select all that apply)

A. assess the client for brusing C determine whether client takes muscle relaxant D instruct client to flex muscle when needle is inserted

A nurse is admitting a client to the orthopedic unit following a total knee arthroplasty. Which of the following actions by the nurse are appropriate? (select all that apply)

A. check continuous passive motion device settings B. palpate dorsal pedal pulses D. elevate heels off bed

A nurse is providing teaching for a client who has a history of lower back injury. Which of the following instructions should the nurse give the client to prevent further problems with low back pain? (select all that apply)

A. engage in regular exercise including walking D. create a smoking cessation plan E. wear low-heeled shoes

A nurse is providing care to a client who is 1 day postoperative following a paracentesis. The nurse observes clear, pale- yellow fluid leaking from the operative site. Which of the following is an appropriate answer?

Apply a dry, sterile dressing

A nurse is completing a preop teaching for a client who is to undergo an arthroscopy to repair injury to a shoulder. Which of the following statements by the nurse is appropriate? (select all that apply)

B inspect your incision daily for signs of infection E perform isometric exercises as directed

A nurse is assessing a client who is to undergo a r knee arthro. Which of the following are expected findings? (select all that apply)

B pain when bearing weight C joint crepitus D swelling of the affected joint E limited joint motion

A nurse is preparing a plan of care to prevent a client from developing flexion contractions following a below the knee amp 24 hr ago. Which of the following should the nurse include in the plan of care?

B position the client prone several times each day

A nurse is teaching a client who has a hiatal hernia. Which of the following client statements indicates an understanding of the teaching?

B. "Peppermint tea will increase my indigestion."

A nurse is teaching a client who has a new diagnosis of pernicious anemia due to chronic gastritis.Which of the following should be included in the teaching?

B. A monthly injection of medication is required

A nurse is providing information about capsaicin (Capsin) cream to a client who reports continuous knee pain from osteoarthritis. Which of the following information should the nurse include in the discussion?

B. Put on gloves before applying the Crean to other parts of the body

A nurse is caring for a client who received a lower back injury during a fall and describes sharp pain in the back and down the left leg. In which of the following positions should the nurse plan to place the client to attempt to decrease the pain?

B. semi-fowlers with a pillow under the knees

A nurse is preparing to administer pancrelipase to a client who has pancreatitis. Which of the following actions should the nurse take?

B: Offer a glass of water following medication administration.

A nurse is reviewing the health record of a client who is to undergo total joint arthroplasty. The nurse should recognize which of the following findings as a contraindication to this procedure?

C previous joint replacement

A nurse is completing discharge teaching for a client who is postoperative following fundoplication. Which of the following statements by the client indicates understanding of the teaching?

C. "I will elevate the head of my bed on blocks."

A nurse is reviewing the health record of a client who has a suspected tumor the jejunum. The nurse should anticipate a prescription for which of the following tests? (Select all that apply)

C. Gastrointestinal X-ray with contrast D. Small bowel capsule endoscopy (M2A)

A nurse is assessing a client who has pancreatitis. Which of the following findings should the nurse identify as a manifestation of pancreatitis?

C: Gray-blue discoloration of the skin around the umbilicus.

A nurse is reviewing bowel prep using polyethylene glycol with a client scheduled for a colonoscopy. Which of the following instructions should the nurse include in the teaching?

Check with the provider about taking current medications when consuming bowel prep.

A nurse is assessing a client who has been taking prednisone following an exacerbation of inflammatory bowel disease. The nurse should recognize which of the following findings as the priority?

Client reports having an elevated body temperature.

A nurse is completing an admission assessment of a client who has pancreatitis. Which of the following findings should the nurse expect?

D: Epigastric pain radiating to the left shoulder

A nurse is reviewing the admission laboratory results of a client who has acute pancreatitis. Which of the following findings should the nurse expect?

D: Increased blood glucose level

A nurse is completing discharge teaching with a client who has Crohn's disease. Which of the following instructions should the nurse include in the teaching?

Drink canned protein supplements.

A nurse is caring for a client who has a small bowel obstruction from adhesions. Which of the following findings are consistent with this diagnosis?

Emesis greater than 500 mL with a fecal odor Report of spasmodic abdominal pain high-pitched bowel sounds

A nurse is teaching a client who has a new prescription for sulfasalazine. Which of the following instructions should the nurse include in the teaching?

Notify the provider if you experience a sore throat.

A nurse on a medical‐surgical unit is admitting a client who has hepatitis B with ascites. Which of the following actions should the nurse include in the plan of care?

Provide a high‐calorie, high‐carbohydrate diet.

A nurse is completing discharge teaching with a client who is 3 days postoperative following a transverse colostomy. Which of the following should the nurse include in the teaching?

Stoma should be moist and pink

A nurse is caring for an older adult client in an extended care facility. Which of the following indicates the client has a stool impaction causing a large intestine obstruction?

The client is having small, frequent liquid stools

A charge nurse is teaching a group of nurses about a client who has chronic gastritis and id scheduled for a selective vagotomy. which of the following statements by a unit nurse indicates understanding of the purpose of the procedure?

The client will have a reduction of gastric acid secretions

A nurse in a clinic is instructing a client about a fecal occult blood test, which requires mailing three specimens. Which of the following statements by he client indicates understanding of the teaching?

This is an easy way to screen for colon cancer.

A nurse is completing an admission assessment of a client who has a small bowel obstruction. Which of the following findings should the nurse report to the provider?

Urine specific gravity 1.040 Hematocrit 60% potassium 3.0 mEq/L

A nurse is performing health screenings of clients at a health fair. Which of the following clients are at risk for osteoporosis? (Select all that apply)

a. A 40yr old client who takes prednisone for asthma c. A 45yr old client who takes phenytoin for seizures d. A 65yr old client who has a sedentary lifestyle e. A 70yr old client who has smoked for 50 years

A nurse is planning discharge teaching on home safety for an older adult client who has osteoporosis. Which of the following information should the nurse include in the teaching? (Select all that apply)

a. Remove throw rugs in walkways b. Use prescribed assistive devices c. Remove clutter from the environment e. Maintain lighting of doorway areas

A nurse is having difficulty arousing a client following an esophogogastroduodenoscopy (EGD). Which of the following is the priority action by the nurse?

assess the clients airway

A nurse is providing care for a client who had a vertebroplasty of the thoracic spine. Which of the following is an appropriate action by the nurse?

b. Place the client in a supine position

A nurse is providing dietary teaching about calcium-rich foods to a client to has osteoporosis. Which of the following foods should the nurse include in the instructions?

b. kale

A nurse is admitting an older adult client who has suspected osteoporosis. Which of the following is an expected finding? (Select all that apply)

b. loss in height of 2 in. (5 cm) c. body mass index (BMI) of 21 d. kyphotic curve at upper thoracic spine e. history of lactose intolerance

A nurse is educating clients at a health fair about dual xray absorpiometry (DXA) scans. Which of the following should the nurse include in the teaching? (select all that apply)

b. the hip and spine are the usual areas the device scans d. bone pain can indicate a need for a scan e. females should have a baseline scan in their 40s

a nurse is caring for a client who had an above the knee amp. the client reports sharp, stabbing type of phantom pain. which type of the following actions should the nurse take?

d. administer an antiepileptic medication

A nurse is planning care for a client who has a small bowel instruction and a nasogastric (NG) tube in place. Which of the following nursing interventions should be included in the plan of care?

document Ng drainage assess bowel sounds provide oral hygiene very 2 hours monitor NG tube for placement

a nurse is teaching a client who has a new prescription for famotidine. which of the following statements by the client indicates understanding of the teaching?

i will take my pill at bedtime

A nurse is completing discharge teaching to a client who has irritable bowel syndrome (IBS). Which of the following should be included in the teaching?

keep a food diary to identify triggers to exacerbation

A nurse is caring for a client who has a new diagnosis of hepatitis C. Which of the following laboratory findings should the nurse expect?

postive EIA test

A nurse is providing discharge teaching to a client who has a new prescription for aluminum hydroxide(Amphojel). The nurse should advise the client to

wait 1 hour before taking other oral medications

A nurse is providing teaching to a client who is scheduled for a bone scan. Which of the following statements by the nurse is appropriate?

you will have to urinate just before the procedure