Med surg 1 ATI #1
A nurse in the emergency department is caring for a client who has an elevated temperature and reports fatigue and muscle aches. Which of the following actions should the nurse take? -Prepare the client for intubation. -Obtain a chest x-ray. -Request a prescription for isoniazid. -Request a prescription for dexamethasone. -Place the client on supplemental oxygen. -Place the client in a negative pressure room.
-Place the client on supplemental oxygen is correct. The nurse should place the client on supplemental oxygen to increase their oxygen saturation and improve their gas exchange. -Obtain a chest x-ray is correct. A chest x-ray is often the most common diagnostic test for a client who has pneumonia. -Request a prescription for dexamethasone is correct. Dexamethasone and other IV steroids are often administered to clients with pneumonia.
A nurse is caring for a client who has heart failure. A nurse is reviewing the assessment findings for the client on day 4. Which of the following findings requires further action? oxygen saturation weight blood pressure urine output temperature breath sounds
-breath sounds -weight -oxygen saturation -blood pressure
A nurse is providing dietary teaching to a client who has chronic kidney disease (CKD). The nurse should instruct the client to limit which of the following nutrients? (SATA) -protein -calcium -calories -phosphorous -sodium
-protein A client who has CKD should restrict protein intake to prevent uremia that can develop as a result of the kidneys' inability to remove the waste products of protein. -phosphorous A client who has CKD is at risk for hyperphosphatemia due to a reduction in excretion of phosphorous by the kidneys. -sodium A client who has CKD is at risk for hypernatremia, edema, and hypertension due to sodium retention.
a nurse is admitting a client who has a history of heart failure. Select the 5 findings that require immediate follow-up. -vital signs -resp. assessment -renal function -cardiac enzymes -BNP -ECG results -neurologic status
-vital signs The nurse should report the client's heart rate as elevated at 138/min. This finding indicates the client is experiencing atrial fibrillation with rapid ventricular response (RVR), which places them at a risk for further decompensation and stroke. If the client's blood pressure decreases further, the client could experience a systemic lack of perfusion. -resp. assessment The client is coughing pink-tinged sputum, which is an indication of pulmonary edema. The client is at risk of decompensation if the condition is not addressed promptly. -renal function The BUN and creatinine levels are above the expected reference range, which indicates possible impaired renal perfusion from weakened cardiac muscle contractions. -BNP The client's BNP is at a critical level, indicating worsening heart failure. -ECG results The ECG shows atrial fibrillation with RVR which is a change in the client's medical condition. This places the client at a risk for further decompensation and stroke.
a nurse reports an incident of suspected elderly abuse. One of the patients children becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate? A. "as a nurse, I am required by law to report suspected elderly abuse." B. "I am unable to discuss this, but I can contact my supervisor to speak with you." C. "The provider will be coming to explain the situation." D. "I reported the incident to my supervisor who decided to contact the authorities."
A. "As a nurse, I am required by law to report suspected elderly abuse." A nurse is required by law to report suspected elder abuse. Therefore, this is a truthful, non-accusatory response.
A nurse is providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching? A. "Eating a high fiber diet will reduce my risk for developing skin cancer" B. "I should check my skin monthly for any changes" C. "I should avoid the use of tanning booths" D. "I should use sunscreen even on cloudy days"
A. "Eating a high fiber diet will reduce my risk for developing skin cancer" a high-fiber diet is recommended to reduce the risk for COLON cancer.
a nurse is teaching a client who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following statements by the client indicates an understanding of the teaching? A. "I will feel shaky" B. "I will be more thirsty than usual" C. "my skin will be warm and most." D. "My appetite will be decreased."
A. "I will feel shaky" Manifestations of hypoglycemia include feeling shaky and nervous.
A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which of the following client statements indicates a need for further teaching? A. "I will need t wipe my perineal area from back to front after urination." B. "I will need to empty my bladder regularly and completely." C. "I will need to drink apple cider vinegar each day." D. "I need to drink 8 cups of liquid each day."
A. "I will need to wipe my perineal area from back to front after urination." Wiping the perineal area from back to front increases the risk for urethral contamination and a resulting UTI.
A nurse is assessing a lesion on a client who has basal cell carcinoma. The nurse should expect which of the following findings? A. a pearly, shiny nodule B. a pigmented papule C. a rough, scaly tumor D. a weeping vesicle
A. a pearly, shiny nodule the most common presentation of basal cell carcinoma is a nodular lesion with well-defined borders that has a pearly or shiny appearance.
A nurse in a provider's office is reviewing the laboratory results of a client who takes furosemide for hypertension. The nurse notes that the client's potassium level is 3.3 mEq/L. The nurse should monitor the client for which of the following complications? A. cardiac dysrhythmias B. hypoglycemia C. seizures D. neurogenic shock
A. cardiac dysrhythmias This client's potassium level is below the expected reference range. Hypokalemia can cause a number of cardiac effects including flattened T waves, prominent U waves, and S-T depression.
The nurse is caring for a client who has heart failure and a history of asthma. The nurse reviews the provider's orders and recognizes that clarification is needed for which of the following medications? A. Carvedilol B. Fluticasone C. Captopril D. Isosorbide dinitrate
A. carvedilol Medications that block beta-2 receptors, such as carvedilol, are contraindicated in clients with asthma.
A nurse is caring for a client who has heart failure and a potassium level of 2.4 mEq/L. The nurse should identify which of the following medications as the cause of the client's low potassium level? A. furosemide B. Nitroglycerin C. metoprolol D. spironolactone
A. furosemide Furosemide is a loop (high-ceiling) diuretic that inhibits the reabsorption of sodium and chloride and results in diuresis, which decreases potassium through excretion in the distal nephrons. Hypokalemia is an adverse effect of furosemide.
A nurse is assessing a client who presents to the provider's office for evaluation of multiple nevi. Which of the following findings should the nurse report to the provider as a possible sign of malignancy? A. irregular borders B. purulent drainage C. uniform pigmentation D. intense pruritus
A. irregular borders Findings associated with malignant changes in a nevus include asymmetry, irregular borders, non-uniform pigmentation, and increased diameter.
A nurse is caring for a client who reports an area of redness, warmth, tenderness and pain in the right calf. The nurse anticipates which of the following orders when notifying the provider of this finding? A. obtain a venous duplex ultrasound B. Obtain independence plethysmography. C. Monitor Homan's sign D. Apply cold therapy to the affected leg.
A. obtain a venous duplex ultrasound. Venous duplex ultrasonography is a noninvasive diagnostic test that assesses the flow of blood and is used to detect distal deep vein thrombosis (DVT).
A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see? A. pH below 7.35 B. HCO3 above 26 mEq/L C. PaO2 below 70 mm Hg D. PaCO2 above 45 mm Hg
A. pH below 7.35 With acidosis, the pH is below 7.35. However, the pH alone does not indicate whether the problem is metabolic or respiratory. A pH above 7.45 indicates alkalosis.
A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH: 7.22 PaCO2: 68 mmHg PaO2: 78 mm Hg Saturation: 80% Bicarbonate: 26 mEq/L A. respiratory acidosis B. metabolic acidosis C. metabolic alkalosis D. respiratory alkalosis
A. respiratory acidosis Respiratory acidosis occurs when there is retention of CO2 due to an impairment of respiratory function. It can be the result of respiratory depression, seen with anesthesia or opioid administration; inadequate chest expansion, due to a weakness of the respiratory muscles or constriction to the thorax; an obstruction of the airway, seen in aspiration, bronchoconstriction, or laryngeal edema; or from an inability of the lungs to adequately diffuse gases (O2 and CO2), resulting from conditions such as pneumonia, COPD, chest trauma, or pulmonary emboli. Arterial blood gases will reveal a pH that is lower than the normal reference range (7.35 - 7.45) and a CO2 level that is higher than the normal reference range (35 - 45 mm Hg).
A nurse is caring for a client who has end-stage renal disease (ESRD). Which of the following are expected findings? (SATA) A. Slurred speech B. bone pain C. bradypnea D. Pruritus E. Hypotension
A. slurred speech B. bone pain D. pruritus
A client who has type 2 diabetes mellitus asks the nurse, "Why did I develop diabetes?" Which of the following responses should the nurse make? A. "your body is destroying the cells that secrete insulin." B. "your body has insulin resistance and decreased insulin secretion." C. "an infection in your pancreas destroyed the cells that make insulin." D. "your kidneys are not able to reabsorb water which leads to Type 2 diabetes mellitus."
B. "your body has insulin resistance and decreased insulin secretion." A client genetically susceptible can develop Type 2 diabetes mellitus when obesity and physical inactivity lead to insulin resistance at cells as well as decreased secretion of insulin by pancreatic beta-cells.
A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client? A. respiratory alkalosis B. Increased anteroposterior diameter of the chest C. oxygen saturation level 96% D. petechiae on chest
B. Increased anteroposterior diameter of the chest The nurse should anticipate an increased anteroposterior diameter of the chest (barrel chest) because of chronic hyperinflation of the lungs.
A nurse is providing discharge teaching to a client who has peripheral arterial disease (PAD). Which of the following instructions should the nurse include in the teaching? A. apply a heating pad on a low setting to help relieve leg pain. B. adjust the thermostat so that the environment is warm. C. Wear antiembolic stockings during the day. D. Rest with the legs above the heart level.
B. adjust the thermostat so that the environment is warm. The client's instructions should include keeping the environment warm to prevent vasoconstriction. Wearing gloves, warm clothes, and socks will help prevent vasoconstriction.
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infections? A. replace the catheter every 3 days. B. check the catheter tubing for kinks or twisting C. irrigate the catheter once each shift D. clean the perineal area with antiseptic solution daily.
B. check the catheter tubing for kinks or twisting. The nurse should check the catheter for twisting or kinks in the tubing. These obstructions can affect the flow of urine causing pooling in the tubing that could backflow into the bladder.
A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect? A. dependent rubor B. edema C. hair loss D. thick, deformed toenails
B. edema An increase in venous hydrostatic pressure, which develops when fluid accumulates in the veins, causes fluid to leak out into the tissues resulting in edema.
A home health nurse is making a home visit to a client who takes a daily diuretic for heart failure. Which of the following manifestations should the nurse identify as indicating the client is hypokalemic? A. pitting edema B. fatigue C. dyspnea D. oliguria
B. fatigue The nurse should expect to find the client with fatigue due to muscle weakness with hypokalemia.
A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB? A. chest x-ray B. sputum culture for acid-fast bacillus C. sputum smear D. mantoux test
B. sputum culture for acid-fast bacillus Although the Mantoux (skin test) and the chest x-ray may be useful screening tools for TB, the presence of acid-fast bacillus noted in the client's sputum, secretions, or tissues is the only method that can actually confirm the diagnosis.
A nurse is teaching about self-monitoring to a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? A. "I will check my urine once a day for ketones." B. "I will notify my provider if pre-meal glucose is 120mg/dL. C. "I will check my blood glucose every 4 hours when I am sick." D. "I will check blood glucose every 5 minutes when lightheaded."
C. "I will check my blood glucose every 4 hours when I am sick" The client should follow specific guidelines when sick. The nurse should instruct the client to monitor blood glucose every 3 to 4 hr and continue to take insulin or oral antidiabetic agents. The client should consume 4 oz of sugar-free, noncaffeinated liquid every 30 min to prevent dehydration and eet carbohydrate needs through soft food if possible. If not, the client should consume liquids equal to usual carbohydrate content. The nurse should also instruct the client to test urine for ketones and report to provider if they are abnormal (the level should be negative to small).
A nurse is teaching a client who has type 1 diabetes mellitus about foot care. Which of the following statements by the client indicates an understanding of the teaching? A. "I'll wear sandals in warm weather." B. "I'll put lotion between my toes after drying my feet." C. "I'll check my feet every day for sores and bruises." D. "I'll soak my feet in cool water every night before I go to bed."
C. "I'll check my feet every day for sores and bruises." The client should check his feet daily to monitor for any problems and observe any other changes before they become serious. He can use a hand mirror to examine areas that are difficult for him to see.
A nurse is caring for the client who has meiniere's disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make? A. "yes, you are free to move around as you wish." B. "No, you are on a strict bedrest and must not be up." C. "Please ring for assistance when you wish to get out of bed." D. "We will have to get a prescription from your provider."
C. "Please ring for assistance when you wish to get out bed." This response is appropriate. With assistance, the client can ambulate safely. Tinnitus, one-sided hearing loss, and vertigo are all manifestations of Ménière's disease that can increase the client's risk of falls when ambulating.
A nurse is teaching a client who has a new diagnosis of type 1 diabetes mellitus about self-administration of insulin. Which of the following instructions should the nurse include? A. "Pull back on the plunger after injecting the insulin." B. "Massage the injection site after removing the needle." C. "Store the current bottle of insulin at room temperature." D. "Use each syringe up to six times."
C. "store the current bottle of insulin at room temperature." The nurse should instruct the client to keep the bottle of insulin she is currently using at room temperature to minimize painful injections. The client should refrigerate unused bottles of insulin to protect the quality of the medication.
A nurse is caring for a client with diabetes mellitus who is prescribed regular insulin via a sliding scale. After administering the correct dose at 0715, the nurse should ensure the client receives breakfast at which of the following times? A. 0720 B. 0730 C. 0745 D. 0815
C. 0745 Regular insulin should be given 20 to 30 minutes before eating because the onset of action is 30 minutes. There are circumstances when this lag time guide can be adjusted.
A nurse is assessing a client who has peritonitis. Which of the following findings should the nurse expect? Which of the following findings should the nurse expect? A. hyperactive bowel sounds B. increased urinary output C. rigid abdomen D. frequent bowel movements
C. Rigid abdomen
A nurse at an outpatient surgery center is providing discharge teaching to a client and his spouse following surgical removal of a cataract. Which of the following should the nurse include in the teaching? A. take ibuprofen for eye discomfort B. creamy white drainage is an indication of infection C. notify the provider immediately if the operative eye itches. D. the client should wear dark glasses while outdoors.
C. The client should wear dark glasses while outdoors. The nurse should instruct the client and his spouse that he should wear dark glasses when outside or in bright light until pupil reaction returns.
A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect? A. nausea B. Dysphagia C. Agitation D. hypotension
C. agitation The nurse should expect agitation due to neurological changes from poor oxygen exchange.
A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency? A. a raised red rash around the fistula site B. pain in the right arm proximal to the fistula site C. cold and numb numbness distal to the fistula site D. foul-smelling drainage from the fistula site.
C. cold and numb numbness distal to the fistula site. Pallor and numbness distal to the fistula site are possible indicators of venous insufficiency and should be immediately reported to the provider.
A nurse is caring for a client who has pruritus following treatment for scabies. Which of the following actions should the nurse take? A. apply additional scabicide to the affected area. B. assist the client to take a hot shower. C. Provide mittens for the client to wear at night. D. Encourage the client to gently rub the affected area.
C. provide mittens for the client to wear at night. Intense itching is a manifestation of scabies that is often reported by clients as unbearable at night. For this reason, the nurse should provide mittens for the client to wear at night to protect the integrity of the skin.
A nurse is giving a presentation at a community center about chronic bronchitis. Which of the following information should the nurse include as effective for preventing this disorder? A. maintenance of ideal weight B. annual influenza immunization C. smoking cessation D. regular moderate exercise
C. smoking cessation Smoking is a major cause of chronic bronchitis; therefore, smoking cessation is an effective preventive strategy.
A nurse is caring for a client who has uncontrolled type 1 diabetes mellitus. Which of the following findings should the nurse expect? A. hypertension B. hematuria C. weight loss D. bradycardia
C. weight loss Weight loss is an expected finding for a client who has uncontrolled diabetes.
A nurse is teaching about disease management for a client who has type 1 diabetes mellitus. Which statement made by the client indicates an understanding of the teaching? A. "I am to take my blood sugar reading after meals." B. "Insulin allows me to eat ice cream at bedtime." C. "A weight reduction program will make me hypoglycemic." D. "I give the insulin injections in my abdominal area."
D. "I give the insulin injections in my abdominal area." The client should give insulin injections in one anatomic area for consistent day-to-day absorption. The abdomen is the area for fastest absorption.
A nurse is providing postoperative teaching to a client who is scheduled for cataract surgery. Which of the following information should the nurse include? A. "Bloodshot eyes on the day of surgery should be reported to the provider." B. "warm compresses should be applied to the eye three times daily." C. "photophobia is expected for 2 to 3 days." D. "Vision will be greatly improved on the day of surgery."
D. "Vision will be greatly improved on the day of surgery." Vision should be greatly improved on the day of surgery. This information should be included in the teaching.
A nurse is teaching a client about the uses of cranberry juice. Which of the following information should the nurse include in the teaching? A. "cranberry juice can lower cholesterol." B. "You may experience bloating." C. "cranberry juice can cause bad breath." D. "Drinking cranberry juice daily can prevent recurrent urinary tract infections."
D. "drinking cranberry juice daily can prevent recurrent urinary tract infections." The client can decrease the risk of having recurrent urinary tract infections by consuming cranberry juice daily, because cranberry juice contains proanthocyanidins a compound that prevent bacteria from adhering to the urinary tract mucosa.
A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes? A. Pigeon B. Funnel C. Kyphotic D. Barrel
D. Barrel clients who have COPD use accessory muscles to assist with respiratory effort. The use of those accessory muscles causes the chest wall to eventually increase in anterior-posterior diameter, making it appear barrel shaped.
A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. The nurse should expect the client to report A. loss of central vision B. having a loss of peripheral vision C. seeing bright flashes of light and floaters. D. having a decreased ability to perceive colors.
D. Having a decreased ability to perceive colors. Symptoms of cataracts include painless blurred vision and a decrease in the ability to perceive colors.
A nurse is preparing to obtain a daily weight from a client who has chronic kidney disease. Which of the following actions should the nurse implement? A. use any available scale to weigh the client B. Balance the scale at minus two before weighing the client C. Obtain the weight each day at a time most convenient for the client. D. Weigh the client after he has voided.
D. Weigh the client after he has voided. The nurse should have the client void before obtaining a daily weight.
A nurse is assessing a female client who is at risk for developing type 2 diabetes mellitus. The nurse should identify that which of the following manifestations increases the client's risk for developing type 2 diabetes? A. abdominal girth 32 inches B. fasting blood glucose 98 mg/dL C. triglyceride level 100mg/dL D. blood pressure 138/98 mm Hg
D. blood pressure 138/98 mm Hg A female client who has a blood pressure greater than 130 mm Hg systolic and 85 mm Hg diastolic is at risk for type 2 diabetes.
A nurse in the emergency department is assessing an older adult client who has community-acquired pneumonia. Which of the following findings should the nurse expect? A. unequal pupils B. hypertension C. Tympany upon chest percussion D. confusion
D. confusion Confusion due to hypoxemia is an expected finding for an older-adult who has pneumonia.
A nurse is assessing an older adult client who reports a sudden onset of urinary incontinence. The nurse should recognize which of the following conditions can cause incontinence in the older adult client? A. nephrosclerosis B. uremia C. diverticulitis D. cystitis
D. cystitis A sudden onset of urinary incontinence or increased confusion can indicate the presence of a urinary tract infection or bacterial cystitis in the older adult client.
A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions? A. maintaining a semi-fowler's position as often as possible B. administering oxygen via nasal cannula at 2L/ min C. helping the client select a low-salt diet D. encouraging the client to drink 2 to 3 L of water daily
D. encouraging the client to drink 2 to 3 L of water daily COPD is a term for two diseases of the respiratory system: chronic bronchitis and emphysema. Maintaining hydration through the consumption of adequate fluids will help liquefy thick secretions and facilitate their expectoration.
A nurse is providing teaching for a client who has a new diagnosis of angina pectoris. The nurse should give the client which of the following information about anginal pain? A. the pain usually last longer than 20 min. B. the pain often radiates to the jaw or back. C. the pain persists with rest and organic nitrates. D. exertion and anxiety can trigger the pain.
D. exertion and anxiety can trigger the pain. Exertion and anxiety can trigger the pain of angina, unless it is variant angina, which occurs at rest.
A nurse is caring for a client who has asthma and is taking fluticasone. The nurse should monitor the client for which of the following adverse effects? A. hypoglycemia B. hypertension C. Polyuria D. oral candidiasis
D. oral candidiasis Fluticasone can cause oral candidiasis, or thrush; therefore, the client should rinse her mouth with water.
A nurse is planning care for a client who has deep vein thrombosis of the lower leg. Which of the following interventions should the nurse include in the plan of care?
Keep the client's affected leg elevated while in bed. The nurse should keep the client's leg elevated when he is in bed to decrease edema.
