ATI Standard Quiz- Medical surgical Final

A nurse is planning care for a client who has acute myelogenous leukemia and a platelet count of 48,000/mm3. Which of the following interventions should the nurse include? A. Avoid IM injections B. Assess the client for ecchymosis once per shift C. Do not allow the client to have visitors D. Encourage daily flossing between teeth

A

A nurse is providing discharge teaching about improving gas exchange to a client who has emphysema. Which of the following instructions should the nurse include in the teaching? A. Use pursed lip rbeahting during periods of dyspnea B. Limit fluid intake to 1,500mL per day C. Practice chest breathing each day D. Wear home oxygen to maintain an SaO2 of at least 94%

A

A nurse in an ER is assessing a client who has extensive burns, including on her face. Which of the following assessments should the nurse perform first? A. Estimation of burn injury B. Characteristics of cough and sputum C. Extent of peripheral edema D. Amount of urine output

B

A nurse is teaching a client about transmission prevention of hepatitis A. The nurse should identify that hepatitis A is transmitted by which of the following routes? A. Maternal fetal B. Fecal oral contamination C. Genital sexual contact D. Blood to blood

B

A nurse is monitoring a client following a thyroidectomy for the presence of hypoparathyroidim. Which of the following findings should the nurse expect? A. Elevated blood pressure B. Involuntary muscle spasms C. Cold intolerance D. Weight loss

B The nurse should identify involuntary muscles spasms as an indication of hypoparathyrodim, which can occur if the parathyroid glands are damaged or removed by a thyroidectomy

A nurse is assessing a client who has a fractured left femur and is in skeletal traction. Which of the following findings should the nurse report to provider? A. Ecchymosis of the thigh B. Serous drainage at the pin site C. Chest petechiae D. Muscle spasms in left leg.

C

A nurse is providing teaching to a client who has TB and a prescription for isoniazid. Which of the following instructions should the nurse include? A. It is necessary to take this medication for the rest of your life to prevent recurrence B. Your provider will monitor your thyroid function while you are taking this medication C. You should take this medication on empty stomach D. It is recommended to take this medication with an antacid

C

A nurse is providing teaching to a client who has a history of tonic clonic seizures and is scheduled for a EEG. Which of the following instructions should the nurse include in the teaching? A. Remain NPO 6-8 hr prior to EEG B. Take a sedative the night prior to EEG C. Thoroughly shampoo hair prior to the EEG D. Sleep for at least 8 hr the night prior to the test

C

A nurse is providing teaching to a client who has TB and Rx for rifampin and ethambutol. The nurse should identify which of the following findings as an adverse effect these medications that the client should report to the provider? A. Red-orange discoloration of urine B. Unexpected weight gain C. Ringing in the ears D. Decreased visual acuity

D The nurse should identify optic neuritis as an adverse effect of ethambutol. The nurse should instruct the client to monitor for changes in visual acuity or color identifiycation as indications of optic neuritis to report to provider.

A nurse is working with an assistive personnel who is assigned to bathe a client who has herpes zoster. The AP asks the nurse if the herpes zoster is contagious. Which of the following responses should the nurse make? A. Adult receive a natural immunity to herpes zoster from casual exposure to children who have had chickenpox B. Herpes zoster is not contagious to individuals who received an MMR vaccine as an infant C. A client who has herpes zoster is not contagious if blisters are present on skin D. Herpes zoster is not contagious to people who have had chickenpox

D The nurse should inform that AP that varicella is the causative agent of both chickenpox

A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which of the following actions should the nurse take? A. Have the client gently blow clots from the nose every 5 min B. Instruct the client to sit with his head hyperextended C. Apply ice compresses to the back of the clients neck D. Apply lateral pressure to the clients nose for 10 min

D The nurse should apply direct, lateral pressure to the nurse for 10 min to control epistaxis. If after 10 min the epistaxis continues, the client might require the nasal packing or other interventions

A nurse is caring for a client who has stage III pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first? A. Obtain the prescribed irrigation solution B. Don personal protective equipment C. Check the clients pain level D. Place a waterproof pad under the clients extremity

C

A community health nurse is teaching a group of clients about melanoma. Which of the following characteristics of lesions associated with melanoma should the nurse include in the teaching? A. One solid color B. Symmetrical in shape C. Less than 6mm in diameter D. An irregular border

D

A home health nurse enters a clients home and finds a used insulin syringe, without a cap, on the table. Which of the following action should the nurse take? A. Recap the needle on the syringe B. Schedule a nurse to administer future injections for this client C. Explain to the client that the syringe should be disposed of in the bathroom trash can D. Place the syringe in a puncture proof disposal container

D

A nurse is providing discharge teaching to a client who has a new diagnosis of SLE. Which of the following statements by the client indicates an understanding of the teaching? A. I will need to take methotrexate even if Im in remission B. Im thankful that this type of lupus only affect the skin C. Each day I should apply a sunblock with a sun protection factor of 15 D. A mild fever is common with SLE and usually does not require medical intervention

A

A nurse is providing discharge teaching to a client who has a new permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching? A. I should check my heart rate at the same time each day B. I dont have to take my antihypertensive medications now that I have a pacemaker C. I should keep a pressure dressing over the generator until the incision is healed D. I cannot stand in front of our new microwave when it is on

A

A nurse is reviewing a clients lab report. The clients ABG levels are pH 7.5, paCO2 32, HCO 24. The nurse should determine that the client has which of the following acid base imbalances? A. Resp. alkalosis B. Metabolic acidosis C. Resp. Acidosis D. Metabolic alkalosis

A

A nurse is teaching about a low cholesterol diet to a client who had a myocardial infarction. Which of the following meal selections by the clients indicates an understanding of the teaching? A. Chicken breast and corn on the cob B. Shrimp and rice C. Cheese omelet and turkey bacon D. Liver and oninos

A

A nurse is the emergency department is caring for a client who has fruity breath odor, dry mouth, and extreme thirst. Which of the following assessments should the nurse make? A. Blood glucose level B. Pupillary reaction to lights C. Deep tendon reflexes D. Liver function test

A

A nurse is planning care for a client who has thrombophlebitis and a Rx to receive herpain via continuous IV infusion. Which of the following actions should the nurse include in the plan of care? A. Infuse the heparin using an electronic IV pump B. Administer vitamin K if the client has indications of hemorrhage C. Adjust the dosage of the heparin base don the PT levels D. Inform the client that the herpain will dissolve thrombus

A The nurse should administer heparin using an electronic IV pump, rather than by gravity, to prevent an accidental increase or change in the rate of infusion

A nurse is caring for a client who is receiving intermittent peritoneal dialysis. The nurse observes that the peritoneal fluid is not adequately draining. Which of the following actions should the nurse take? A. Turn the client from side to side B. Elevate the height of the dialysate bag C. Lower head of bed D. Advance the catheter approximately 2.5cm further

A The nurse should assist the client in turning from side to side to facilitate removal of peritoneal drainage.

A nurse is providing teaching to a client who has cervical cancer and is scheduled to receive brachytherapy in an ambulatory care clinic. Which of the following statements by the client indicates an understanding of the teaching? A. I need to lie still in bed during my brachytherapy treatment B. I will have an implant placed once a month during brachytherapy treatment C. I must stay at least 3 feet away from others between brachytherapy treatments D. I should expect some blood in my urine after each brachytherapy treatment

A The nurse should conform that the client understands the need to remain on bed rest with limited movement while the radioactive implant is in place to prevent dislodgement

A nurse is planning care for a client who had a stroke. The client has hemiplegia and occasional urinary incontinence. Which of the following actions should the nurse include in the clients plan of care? A. Offer the client a bedpan every 2 hours B. Limit the clients daily fluid intake until he is no longer incontinent C. Request a prescription for an indwelling urinary catheter from the clients provider D. Ambulate the client to the bathroom every 30min

A Following a stroke the client might have bladder incontinence due to confusion, impaired sensation in response to bladder fullness, and decreased sphincter control

A nurse is preparing to change the bed linens of a client who has AIDS and is continent of stool Which of the following PPE should the nurse don prior to providing client care (SATA)? A. Gown B. Gloves C. Mask D. Hair cover E. Goggles

A B

A nurse is providing teaching to a client who has gout and urolithiasis. The client asks how to prevent future uric acid stones. Which of the following suggestions should the nurse make? sata A. Take allopurinol as prescribed B. Exercise several times a week C. Limit intake of foods high in purine D. Decrease daily fluid intake E. Avoid citrus juices

A B C

A nurse is performing an admission assessment for a client who has asthma and report several food allergies. Which of the following actions should the nurse take first? A. Document the clients food allergies on the medical record B. Ask the client to identify the specific food allergies C. Monitor the client for indications of anaphylaxis D. Have epinephrine aviabale for administration

B

A nurse is planning dietary teaching for a client who has DM. Which of the following actions should the nurse plan to take first? A. Obtain sample menus from the dietician to give to the client B. Ask the client to identify the types of foods she prefers C. Identify the recommended range for the clients blood glucose level D. Discuss long term complications that can result from nonadherence to pal

B

A nurse is providing teaching about antiretroviral medication therapy to a client who has a new diagnosis of AIDS. Which of the following statements should the nurse include in the teaching? A. Your provider will prescribed one single antiretroviral medication at a time B. You should take antiretroviral medications on a routine schedule C. You should increase your intake of raw fruits and veggies while taking antiretroviral meds D. Your provider will prescribed antiretroviral therapy to kill the HIV virus

B

A nurse is caring for a client who has type 1 DM and a cap glucose reading of 48. Which of the following findings should the nurse expect? A. Kussmaul respirations B. Diaphoresis C. Decreased skin turgor D. Ketouria

B A nurse should expect a client who has a blood glucose level below 70 to exhibit manifestations of hypoglycemia. Expecting findings associated with hypoglycemia include weakness, hunger, diaphoresis, nausea, shakiness and confusion

A nurse is caring for a client who is 72 hr postoperative following an above the knee amputation. Which of the following actions should the nurse take? A. Elevate the residual limb on a soft pillow B. Assist the client to a prone position every 4 hour. C. Reapply a bandage to the residual limb every 12 hour D. Apply dressings to the site in a proximal to distal direction

B The nurse should assist the client to a prone position for 20-30 min every 3-4 hour following an amputation because it reduces the risk for flexion contractures

A nurse in an ER is assessing a client who sustained a fall off a roof. Which of the following findings should the nurse identify as an indication of a basilar skull fracture? A. A depressed fracture of the forehead B. Clear fluid coming from the nares C. Motor loss on one side of the body D. Bleeding from the top of the scalp

B The nurse should idenitfy cerebrospinal fluid, which appears as a clear fluid, coming from the nares or ears as an indication of a basilar skull fracture

A nurse is caring for a client who is to have his chest tube removed. Which of the following actions should the nurse take? A. Cover the insertion site with a hydrocolloid dressing after removal B. Provide pain medication immediately after removal C. Instruct the client to perform the Valsalva maneuver during removal D. Delegate removal of the chest tube to a LPN

C The nurse should instruct the patient to perform the Valsalva maneuver during removal to maintain the appropriate amount of negative pressure in the chest to prevent air entry into the pleural space.

A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following findings should the nurse report to the provider? A. output equal to the instilled irrigant B. Report of bladder spasms C. Viscous urinary output with clots D/ Report of a strong urge to urinate

C The nurse should report urine output that is bright red with clots or urine that resembles ketchup to the provider because this is an indication of arterial bleeding

A nurse in an emergency department is caring for a client who reports developing severe right eye pain with a gritty sensation while sawing wood. Which of the following actions should the nurse take first? A. Instill proparacaine hydrochloride eyedrops B. Perform ocular irrigation of the right eye C. Place the client in a suspine position with the head turned toward the affected side D. Ask the client about the first aid performed at the scene

D

A nurse is caring for a client following a hip arthroplasty. The nurse places an abduction pillow on the client for which of the following purposes? A. Raising the bed linens off the clients feet to prevent plantar flexion B. Keeping the clients heels off the bed to prevent pressure ulcers C. Positioning the client off the operative site while in bed D. Preventing dislocation of the hip during position changes or movement

D

A nurse is teaching a client how to perform a breast self exam. The nurse should identify which of the following findings as an indication of breast cancer? A. Lumps that are mobile and tender upon palpation prior to period B. Multiple round masses that are tender and found in both breasts C. Bilaterally darkened areolas D. A nontender, hard lump that is palpated in one breast

D

A nurse is providing postoperative care for a client who has two chest tubes in place following a lobectomy. The client asks the nurse the reason for having two chest tubes. The nurse should inform the client that the lower chest tube is placed for which of the following reasons? A. Removing air from the pleural space B. Creating access for irrigating the chest cavity C. Evacuating secretions from the bronchioles and alveoli D. Draining blood and fluid from the pleural space

D The nurse should inform the client that blood and fluids tend to accumulate in the bases and posterior areas of the pleural cavity following a lobectomy.

A nurse is caring for a client who has an upper gastrointestinal bleed and a hematocrit of 24%. Prior to initiating a transfusion of packed red blood cells, which of the following actions should the nurse take? SATA A. Assess and document the vitals B. Restart the IV with a 22 G C. Verify with another nurse the blood type and Rh of packed RBCs D. Hang a bag of LR IV solution E. Change IV tubing to set that has a filter

A C E

A nurse is caring for a client who is receiving TPN. Which of the following actions should the nurse take? A. Administer 0.9% sodium chloride until TPN is available from the pharmacy B. Check the clients cap blood glucose level every 4 hour C. Obtain the clients weight each week D. Change IV tubing every 3 days

B The nurse should check the clients cap blood glucose level every 4 hour, or according to facility policy, due to the clients risk for hyperglycemia while receiving TPN. The dextrose concentration in TPN places the client at risk for this complication

A nurse is providing teaching to a client who has stomatitis due to chemo and radiation therapy. Which of the following statements by the client indicates a need for further teaching? A. I will use a soft toothbrush or foam swab for oral care B. I will use lemon and glycerin swabs after meals C. I will remove my dentures except while eating D. I will rinse my mouth frequently with hydrogen peroxide solution

B The nurse should identify that this client statement indicates a new for further teaching.

A nurse is providing discharge teaching to an adult female client who has infective endocarditis about how to prevent recurrence. Which of the following statements by the client indicates understanding of the teaching? A. I will ask my provider to change your contraception to an intrauterine device B. I will notify my doctor before I have dental procedures C. I will avoid using antiseptic mouthwash during my oral care D. I will wear a mask when I go out in public

B The nurse should inform the client of ways to decrease the risk of recurrence of infective endocarditis. The client should notify the provider prior to invasive or dental procedures due to the need for prophylactic antibiotic therapy to reduce the risk of a step infection

A nurse is caring for a client who has encephalitis due to west nile virus. Which of the following actions should the nurse take? SATA A. Place the client on respiratory isolation B. Monitor vital signs every 2 hours C. Assess neuro status every 4 hour D. Maintain the client in a modified trendelenburg position E. Keep the clients room darkened

B C E

A nurse is obtaining a weekly weight for a client who has obesity and osteoarthritis and is on a weight management program. The nurse determines that the client gained 3 pounds in the past week. Which of the following statements should the nurse make? A. You should try a little harder to stick to your diet B. Why do you think you've gained 3 pounds this week C. Were there any issues last week that kept you from focusing on your diet D. You should put this week behind you and adhere to your diet from this point forward

C

A nurse is preparing to care for a group of clients after receiving change of shift report. Which of the following clients should the nurse assess first? A. A client who has a BPH and reports dysuria B. A client who has ulcerative colitis and reports diarrhea C. A client who has emphysema and reports dyspnea D. A client who has esophageal cancer and reports painful swallowing

C

A nurse is caring for an adult male client who is undergoing screening test for atherosclerosis. Which of the following lab findings should the nurse identify as an increased risk for this disorder? A. Cholesterol level 195 B. Elevated HDL levels C. Elevated LDL levels D. Triglyceride 135

C The nurse should identify that an elevated LDL level increases a clients risk for artherosclerosis. The clients desirable LDL level is below 100.

A nurse is providing teaching to a client who has a new diagnosis of MS. The clients asks the nurse about the usual course of MS. Which of the following responses should the nurse make? A. Each client is different, we cannot predict what will happen B. I can see that you are worried, but its too soon to predict what will happen C. Acute episodes are usually followed by remissions, which can vary in duration D. Its too early to think about the future, lets focus on the present and take one day at a time

C The nurse should identify that the client is asking an information seeking question. The nurse should provide the client with factual information. The nurse should inform the client that MS is a chronic autoimmune disorder that is characterized by remissions and exacerbations, with exacerbations becoming more frequent and intense as the disease progresses

A nurse is preparing to administer eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take? A. Instruct the client to blink several times after instilling the medication B. Ask the client to look straight ahead during instillation of the medication C. Apply pressure to the puncta after instilling the medication D. Place each drop of the medication directly on to the clients cornea

C The nurse should instill the medication into the conjunctival sac and apply pressure to the puncta for 1-2 min afterwards to prevent systemic absorption of the medication

A nurse is caring for a client who begins having a tonic clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first? A. Provide oxygen B. Place the client in a side lying position C. Provide privacy D. Lower the client to the floor

D

A nurse is planning care for a client during a sickle cell crisis. Which of the following interventions should the nurse include in the clients plan of care? A. Maintain the clients knees and hips in a flexed position B. Apply cold compresses to painful joints C. Withhold opioids until crisis is resolved D. Encourage increased fluid intake

D

A nurse is providing teaching to a client who is scheduled for a sigmoid colon resection with colostomy. Which of the following statements by the client indicates a need for further teaching? A. Because most of my colon is still intact and functioning, my stool will be formed B. My stoma will appear large at first, but it will shrink over the next several weeks C. My colostomy will begin to function 2-6 days after surgery D. My diet will have to change to a soft diet after surgery

D