medsurg ati practice exam fall
A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take?
Perform pre-oxygenation prior to suctioning.
A nurse is assessing a client who is postoperative following a right below-the-knee amputation. Which of the following findings should the nurse identify as a possible complication?
Presence edema above the stump dressing
A nurse is assessing a client who is postoperative following a vaginal hysterectomy. Which of the following findings is a manifestation of deep-vein thrombosis (DVT)?
decreased pedal pulses
A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect?
fatigue
A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock?
increased heart rate
A nurse is caring for a client who has undergone a transurethral prostatectomy. Following catheter removal, the nurse should inform the client that he should expect which of the following variations in the color of his urine?
pale pink
A nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?
Airway patency
A nurse is calculating the output of a client at the end of the shift. The nurse notes the following: client voided 400 mL at 1100 and 350 mL at 1430. The closed chest drainage system was previously marked at 155 mL and is now at 175 mL. The NG tube has 575 mL in drainage container, and 25 mL is emptied out of the Jackson-Pratt drainage tube. How many mL should the nurse record in the medical record as the client's output?
void= 750 Chest tube= 20 NG= 575 JP= 25 total= 1370 mL
A nurse is caring for a client who is postoperative following an intermaxillary fixation as a result of multiple facial fractures. Which of the following types of equipment should the nurse plan to have at the client's bedside?
wire cutters
A nurse is caring for a client who is postoperative following a below-the knee-amputation and will soon undergo fitting for a leg prosthesis. Which of the following is an appropriate nursing intervention for this client at this time?
wrap the stump with an elastic bandage in a figure-eight configuration.
A nurse is caring for a client who has lung cancer and is scheduled for a lobectomy. The nurse should prepare the client to expect which of the following after the procedure?
A chest tube
A nurse is providing care for four clients on a medical-surgical unit. Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select all that apply.)
A client who has protein calorie malnutrition A client who has right-sided heart failure and 4+ edema to the lower extremities A client who has postoperative delirium
A nurse is providing preoperative teaching for a client who is scheduled for a gastrectomy. Which of the following information regarding prevention of postoperative complications should the nurse include in in the teaching?
Instruct the client about the use of a sequential compression device.
A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider?
"I need something for the pain in my eye. I can't stand it."
A nurse in a one-day surgery center is providing discharge teaching for a client who is postoperative following a partial meniscectomy. Which of the following instructions should the nurse include?
Begin full weight bearing.
A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?
Continue to monitor the client's respiratory status.
A nurse is caring for a client 4 hr postoperative following a kidney biopsy. Which of the following interventions should the nurse take? (Select all that apply).
Monitor for hematuria. Check for flank pain.
A nurse is caring for a client who is postoperative following a laminectomy with spinal fusion. Which of the following actions should the nurse take?
Monitor sensory perception of the lower extremities.
A nurse is admitting a young adult client who has suspected bacterial meningitis. The nurse should closely monitor the client for increased intracranial pressure (ICP) as indicated by which of the following findings?
Widened pulse pressure
A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion?
confusion
A nurse in a clinic is caring for a client requiring a hysterectomy who states that she has decided to delay having this surgery for several months. Which of the following statements should the nurse make?
"Can you elaborate on your reasons for delaying the surgery?"
A nurse is caring for a client who is scheduled for an arthroplasty. The nurse asks client to state if he understands the procedure that is being performed. Which of the following statements by the client indicates an understanding of the procedure?
"This procedure will replace my joint to improve function."
A nurse is caring for a client who has an NG tube set to low intermittent suction. The nurse irrigates the NG tube twice with 30 mL of normal saline solution during his shift. At the end of the shift, the NG canister contains 475 mL. What amount of NG drainage should the nurse record? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) mL
475-60= 415mL
A nurse is assessing a client who is being admitted from the PACU following an abdominal hysterectomy. Which of the following assessments is the nurse's priority?
O2 saturation
A nurse is caring for a client who is 8 hr postoperative following a subtotal thyroidectomy. In which of the following positions should the nurse keep the client?
Semi-Fowler's with neck in a neutral position
A nurse is providing teaching for a client who is postoperative following below-the-knee amputation. The nurse should instruct the client that which of the following nutrients is necessary for would healing?
Vitamin C
A nurse is preparing a client who is postoperative following a below-the knee amputation for a leg prosthesis fitting. Which of the following actions should the nurse take?
Wrap the stump with an elastic bandage in a figure-eight configuration.
A nurse is teaching a client who is preoperative for a colectomy. The client asks the nurse why he needs a large-bore NG tube. Which of the following statements should the nurse make?
"The tube will remove gas and fluid from your stomach."
A nurse is teaching a client who is preoperative how to do deep-breathing exercises and cough effectively after surgery. Which of the following statements by the client indicates an understanding of the teaching?
"I'll splint my incision with a pillow to cough."
A nurse is providing teaching to a client who has a new colostomy. Which of the following information should the nurse include in the teaching?
"You may experience a small amount of bleeding around the stoma."
A nurse is providing discharge teaching to a client following an abdominal hysterectomy. Which of the following information should the nurse include in the teaching?
"You should refrain from sexual intercourse for at least 4 weeks."
A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?
Decreased level of consciousness
A nurse is caring for a client who has a postoperative ileus and an NG tube that has drained 2,500 mL in the past 6 hr. Which of the following electrolyte imbalances should the nurse monitor the client for?
Decreased potassium level
A nurse is assessing a client who is 24 hr postoperative following an open reduction and internal fixation to repair a fracture of the femur. Which of the following assessment findings is an early manifestation of fat embolism syndrome (FES)?
Dyspnea
A nurse is teaching an older adult client who is postoperative following insertion of a permanent pacemaker. The nurse should instruct the client to notify the provider about which of the following manifestations?
Fatigue
A nurse is caring for a client who is 2 days postoperative following an above-the knee-amputation. Which of the following is an appropriate nursing intervention for this client at this time?
Have the client lie prone every 3 hr for 20 min at a time.
A nurse is planning care for a client who is 2 hr postoperative following a transurethral resection of the prostate. The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include?
Remind the client he might feel a constant urge to void.
A nurse is caring for client who just returned from the PACU with an IV fluid infusion and an NG tube in place following abdominal surgery. Which of the following data is the priority for the nurse to assess?
The surgical dressing
A nurse is talking with a client who is scheduled for surgery to repair retinal detachment. Which of the following preoperative instructions should the nurse include?
Restrict head movement.
A nurse is caring for a client who has a tracheostomy. Which of the following interventions should the nurse implement when performing tracheostomy care?
Secure new tracheostomy ties before removing old ones.
A nurse is reviewing the laboratory test results of a client who is scheduled for a carotid endarterectomy in 3 days. Which of the following results should the nurse report to the provider?
Sodium 151 mEq/L
A nurse is caring for a client who is postoperative following knee arthroplasty and has a continuous passive motion (CPM) machine. Which of the following actions should the nurse take?
Store the CPM machine on the floor when not in use.
A nurse is caring for a client who has a Jackson-Pratt (JP) drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which of the following purposes?
To prevent fluid from accumulating in the wound
A nurse is providing discharge teaching for a client who is postoperative following an inner maxillary fixation for facial fractures. Which of the following instructions should the nurse include in the teaching?
keep wire cutters with you
A nurse is caring for a client who has just undergone insertion of a femoral head prosthesis. The nurse should instruct the client to avoid which of the following activities?
putting on shoes and socks
A nurse is caring for a client who is 4 hr postoperative following a hip replacement. The nurse should instruct the client to avoid which of the following activities?
putting on shoes and socks
A nurse is teaching a client who had a total knee arthroplasty about self-administering morphine via a patient-controlled analgesia (PCA) infusion device. Which of the following client statements indicates an understanding of the teaching?
"I should tell the nurse if I can't control my pain with this device."
A nurse is providing teaching about ileostomy care to a client. Which of the following statements by the client indicates a need for further teaching?
"I will be certain to take enteric-coated medications."
A nurse is providing information about pain control for a client who has acute pain following a subtotal gastric resection. Which of the following client statements indicates an understanding of pain control?
"I will call for pain medication as my pain starts to increase again."
A nurse is caring for a client following a right total hip arthroplasty. Postoperatively the nurse should maintain the right leg in which of the following positions?
Abduction.
A nurse is planning postoperative care for a client who is scheduled for an ileal conduit procedure. The nurse should include which of the following in the client's plan of care? (Select all that apply).
Apply skin barrier around the stoma site. Educate the client that hematuria is expected following the procedure. Monitor hourly urine output.
A nurse is providing teaching to a client who has had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine cancer. Which of the following instructions should the nurse include in the teaching?
Artificial lubrication can be used to treat vaginal itching and dryness.
A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?
Blood pressure 115/68 mmHg Rationale: The sympathetic nervous system is stimulated, resulting in the release of epinephrine and norepinephrine. These catecholamines help maintain the client's blood pressure remains within normal limits during the compensatory stage of shock.
A nurse is providing discharge teaching for a client who is postoperative following a simple mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include?
Do not apply heat to the area of irradiation.
A nurse is caring for a client who has a newly inserted chest drainage system with a water seal. Which of the following actions should the nurse take?
Keep the collection device below the level of the client's chest.
A nurse is caring for a client who is 1 day postoperative following hip open reduction with internal fixation. The client is scheduled to begin physical therapy in 30 min. Which of the following actions should the nurse take?
Offer to administer analgesia.
A nurse is caring for a client who has just returned from the PACU after a traditional cholecystectomy. In which of the following positions should the nurse place the client?
Semi-Fowler's
A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following?
Serosanguineous
A nurse is changing the dressing of a client who is 1 week postoperative following abdominal surgery and notes the presence of serosanguineous drainage. The nurse should recognize that this is an indication of which of the following circumstances?
Serosanguineous drainage at this time is a manifestation of possible dehiscence.
A nurse is caring for a client who is 1 day postoperative following a mastectomy. Which of the following exercises should the nurse assist the client to perform on the affected side? (Select all that apply.)
Squeezing a rolled washcloth Flexing and extending her hand Flexing and extending her elbow
A nurse is preparing a client who is scheduled to undergo a paracentesis. Into which of the following positions should the nurse assist the client for this procedure?
Supine
A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include?
avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.
A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first?
check the tubing for kinks
A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for clients who have surgical incisions. Which of the following factors should the nurse include in the teaching? (Select all that apply.)
poor nutrition wound infection obesity
A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?
Increased respiratory rate
A nurse is assessing a client who has developed atelectasis postoperatively. Which of the following findings should the nurse expect?
Increasing dyspnea
A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse the client's peristalsis is returning?
Passage of flatus
A nurse is providing teaching for a client who is preparing for a below the knee amputation. Which of the following statements is true regarding the postoperative placement of a prosthesis?
"You will do special exercises in advance of getting your prosthesis."
A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?
suction two to three times with 60 second pause between passes
A nurse is assessing a client who is to undergo a left lobectomy to treat lung cancer. The client tells the nurse that she is scared and wishes she had never smoked. Which of the following responses should the nurse make?
"It's okay to feel scared. Let's talk about what you are afraid of."
A nurse is providing postoperative teaching to a client who is scheduled for cataract surgery. Which of the following information should the nurse include?
"Photophobia is expected for 2 to 3 days."
A nurse is providing postoperative teaching with a client who had a surgical correction of hallux valgus. Which of the following information should the nurse include in the teaching?
"Rest frequently with your foot elevated."
A nurse is providing discharge instructions for a client following cataract surgery with insertion of an intraocular lens. Which of the following instructions should the nurse include?
"Restrict lifting objects greater than 10 pounds."
A client is about to undergo an abdominal paracentesis. In which of the following positions should the nurse place the client?
supine
A nurse is caring for a client who is using a patient-controlled analgesia (PCA) pump for postoperative pain management. The nurse enters the room to find the client asleep and his partner pressing the button to dispense another dose. Which of the following responses should the nurse make?
"Your husband should decide when more medication is needed."
A nurse is caring for a client who has a severe gangrenous infection of the right lower extremity. The nurse should plan preoperative teaching based on the possibility of which of the following amputation procedures?
"Your pain will gradually become less severe."
A home health nurse is teaching an older adult client who just had cataract surgery. Which of the following instructions should the nurse include?
"keep your head up and straight."
A nurse is monitoring the urinary output of an adult client who had a colon resection. Which of the following 24 hr output totals indicates oliguria?
30 ml per hour x 24 hrs = 720 mL
A nurse is discussing kidney transplant with a client who has end-stage renal disease (ESRD). Which of the following should the nurse identify as a contraindication for this treatment?
Alcohol use disorder
A nurse is completing discharge teaching with a client following arthroscopic knee surgery. Which of the following instructions should the nurse include in the teaching?
Apply ice to the affected area.
A nurse is caring for a client who is postoperative following abdominal surgery. The nurse discovers a loop of bowel through an opening in the surgical incision. Which of the following actions should the nurse take?
Apply moistened sterile gauze to the site.
A nurse is caring for a client who is 1 day postoperative following a transsphenoidal hypophysectomy. While assessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the following should be the nurse's initial action?
Check the drainage for glucose.
A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidectomy. The client reports a tingling sensation in the hands, the soles of the feet, and around the lips. For which of the following findings should the nurse assess the client?
Chvostek's sign
A nurse is assessing a client who is 1 day postoperative following a lobectomy and has a chest tube drainage system in place. Which of the following findings by the nurse indicates a need for intervention?
Development of subcutaneous emphysema
A nurse is caring for an older adult client who has had surgery for an intestinal obstruction and has an NG tube to wall suction. Which of the following interventions should the nurse include in the client's postoperative plan of care? (Select all that apply.)
Discontinue suction when assessing for peristalsis Irrigate the NG tube with 0.9% sodium chloride irrigation solution. Place sequential compression devices on the bilateral lower extremities. Reposition the client from side to side every 2 hr.
A nurse is assessing a client who will undergo abdominal surgery in 2 hr. The client reports being nervous about the surgery, last had food and fluids at 2330 the previous evening, and signed the surgical consent 2 days ago. Which of the following is an appropriate nursing action regarding these findings?
Document the findings in the client's medical record.
A nurse is teaching a client who has a prosthetic limb due to a right below-the-knee amputation about prosthesis and stump care. Which of the following instructions should the nurse include in the teaching?
Dry the prosthesis socket completely before applying it to the limb.
A nurse is caring for a client who is 3 days postoperative following an above-the-knee amputation. Which of the following actions should the nurse take?
Have the client lie prone several times per day.
A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse the client is experiencing an increase in intracranial pressure (ICP)? (Select all that apply.)
Headache Neck pain and stiffness Slurred speech Disorientation
A nurse is caring for a client who is postoperative following a transurethral resection of the prostate. Which of the following complications is the priority for the nurse to monitor for?
Hemorrhage
A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative. Which of the following surgical procedures places the client at risk for deep-vein thrombosis?
Hip arthroplasty
A nurse is caring for a client 1 day postoperative who has developed atelectasis. Which of the following manifestations is an expected finding for this condition?
Hypoxemia
A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider immediately?
Increased heart rate
A nurse is caring for a client with a tracheostomy. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge?
Performing the procedure independently
A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first?
Test the drainage for glucose.
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?
The client should wear dark glasses while outdoors.
A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the nurse expect?
Intercostal retractions
A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?
No fluctuations in the water seal chamber
A nurse is caring for a client following surgical treatment for a supratentorial brain tumor. Which of the following interventions should the nurse take?
Notify the provider for drainage greater than 80 mL/8hr.
A nurse is caring for a client who is HIV positive and is one day postoperative following an appendectomy. The nurse should wear a gown as personal protective equipment when taking which of the following actions?
Completing a dressing change
A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration?
Continue to monitor the client.
A nurse is caring for a client who is 12 hr postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations?
Continuous bubbling in the water-seal chamber
A nurse is caring for an older adult client who has just returned from PACU after receiving a spinal anesthetic during knee surgery. For which of the following findings should the nurse notify the provider?
Systolic blood pressure changed from 140 mm Hg to 120 mm Hg
A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first?
Cover the wound with a moist, sterile gauze dressing.
A nurse is assessing a client who is postoperative and finds the client's abdominal incision has eviscerated. Which of the following actions should the nurse take?
Cover the wound with a sterile saline-soaked dressing.
A nurse is reviewing the prescriptions for a client who had a total hip arthroplasty. Which of the following prescriptions should the nurse verify with the provider?
Instruct the client to restrict flexion of the hip past 120°.
A nurse is caring for a client following a total laryngectomy. Which of the following is the priority observation in the client's care?
Need for suctioning.
A nurse is caring for a client who is 2 hr postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view to be an indication of a postoperative complication?
Output of burgundy colored urine
A nurse is assessing a client who reports ear pain for the past 3 days that has suddenly resolved. The client has a new onset of otorrhea (drainage from the ear). The nurse should recognize the client has manifestations of which of the following conditions?
Perforated tympanic membrane
A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the postoperative period?
Perform neurovascular checks of the extremities.
A nurse is assessing the elastic bandage on the stump of a client who had a right below-the-knee amputation. Which of the following findings should the nurse identify as a complication?
Pitting edema around the stump dressing
A nurse is giving instructions to a client who had a surgical correction of a bunion. Which of the following information should the nurse include?
Place pillows under the knee to elevate the foot.
A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take?
Preoxygenate the client with 100% oxygen for up to 3 min.
A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take?
Prevent aspiration.
A nurse is planning care for a client who is postoperative following a total hip arthroplasty. Which of the following interventions should the nurse include in the plan of care?
Prevent hip flexion of the affected extremity
A nurse is caring for a client who is 1 day postoperative following a left radical mastectomy. Which of the following behaviors should alert the nurse to the possibility that the client is having difficulty adjusting to the loss of her breast?
Refusing to look at the dressing or surgical incision
A nurse is completing discharge teaching to a client about nutrition therapy for wound healing following major surgery. Which of the following vitamins that promote wound healing should the nurse include in the teaching? (Select all that apply.)
Vitamin A Vitamin B12 Vitamin C Vitamin K
A nurse is reviewing the diagnostic test results of an older adult female client who is preoperative for a knee arthroplasty. The nurse should notify the surgeon of which of the following results?
WBC count 20,000/mm3
A nurse is caring for a client in the emergency department who had a traumatic amputation of his left arm in an industrial accident. The nurse should expect the client to be experiencing which of the following of Kubler-Ross's stages of grief?
denial
A nurse is caring for a client who is postoperative following a total hip arthroplasty. The nurse assists the client into a supine position. Which of the following actions is appropriate to prevent dislocation of the hip?
Place a wedge pillow between the legs.
A nurse is caring for a client who is postoperative following an inner mandibular fixation for a fractured mandible. Which of the following actions should the nurse take?
Place wire cutters at the client's bedside.
An occupational health nurse is instructing workers at an industrial facility about emergency procedures to take in the event of a traumatic amputation of a finger. Which of the following guidelines should the nurse include for preserving an amputated part for possible surgical reattachment? (Select all that apply.)
Wrap the amputated finger in dry, sterile gauze. Put the amputated finger in a sealed, waterproof plastic bag. Prevent the amputated finger from contacting water.
A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
Yellow-green drainage on the surgical incision
A nurse is providing discharge teaching to a client following hip arthroplasty. Which of the following pieces of furniture should the nurse instruct the client to sit in at home?
a straight-backed chair with an elevated seat
A nurse is caring for a client 8 hr postoperative following a total knee replacement. Which of the following actions should the nurse take?
bedrest for 5-7 days
A nurse is teaching a client who is postoperative following the insertion of a permanent pacemaker. Which of the following instructions should the nurse include? (Select all that apply.)
count your pulses for one minute each morning do not wear tight clothing over the insertion area
A nurse is caring for a client who is 1-day postoperative following spinal fusion. Which of the following actions should the nurse take?
log roll the client every 2 hours
A nurse is caring for a client who is 1-day postoperative following total hip arthroplasty. It is 0830 and the client is schedule for physical therapy (PT) at 0900. Which of the following interventions should the nurse take?
Identify the client's pain level and medicate if needed.
A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. After calling for help, Which of the following actions should the nurse take first?
Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation.
A nurse is assessing a client 1 day postoperative following abdominal surgery. Suddenly the client reports a pulling sensation and pain in his surgical incision. Which of the following actions should the nurse take?
Cover the area with saline-soaked sterile dressings.
A nurse is caring for a client who is postoperative following vascular surgery. Which of the following signs should indicate to the nurse that the client has developed a thrombus?
Dull, aching calf pain
A nurse is planning care for a client who states he is anxious concerning abdominal surgery. Which of the following actions should the nurse take?
Encourage the client to express negative emotions.
A nurse is providing discharge instructions to a client who developed deep-vein thrombosis (DVT) postoperatively and is prescribed anticoagulant therapy. Which of the following instructions should the nurse include?
Flexing her knees and feet frequently
The nurse is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly?
Fluctuation of the fluid level within the water seal chamber
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?
Increased anteroposterior diameter of the chest
A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify?
MRI of the chest
A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?
Muffled heart sounds.
An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client?
Plantar flexion of the legs
A nurse is developing a plan of care for a client who is postoperative following a pneumatic retinopexy to repair a detached retina. Which of the following interventions should the nurse include in the plan?
Position the client prone.
A nurse in the post-anesthesia care unit is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give highest priority to?
arterial blood gases
A nurse is caring for a client who is postoperative following an open reduction internal fixation (ORIF) of a femur fracture. Which of the following parameters should the nurse include in the evaluation of the neurovascular status of the client's affected extremity? (Select all that apply.)
color temp sensation
A nurse is caring for a client who has a disposable three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication?
continuous bubbling in the water-seal chamber
A nurse is caring for a child who is 2 hr postoperative following a tonsillectomy. Which of the following fluid items should the nurse offer the child at this time?
crushed ice
A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?
encourage the use of an incentive spirometer
A nurse is caring for a client who has a closed suction drain. Which of the following actions should the nurse take? (Select all that apply.)
expect a moderate amount of drainage empty the collection chamber using sterile technique.
A nurse is caring for a client who is two days postoperative following creation of an ileal conduit. Which of the following is an unexpected finding associated with this procedure?
feces in the drainage appliance
A nurse is planning care for a client who is postoperative and at risk for paralytic ileus. Which of the following interventions should the nurse plan to take to promote peristalsis?
increase ambulation
A nurse is caring for a client who is 1-day postoperative following spinal fusion. Which of the following actions should the nurse take?
log roll the client every 2 hr
A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions?
massaging her legs
A nurse is assessing a client who is 3 days postoperative following abdominal surgery and notes the absence of bowel sounds, abdominal distention, and the client passing no flatus. Which of the following conditions should the nurse suspect?
paralytic ileus
A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication?
reduce edema of the brain
A nurse in a critical care unit is caring for a client who is postoperative following a right pneumonectomy. After extubation from the ventilator, in which of the following positions should the client be placed?
semi-fowlers
A nurse is caring for a client who is 9 days postoperative following a total laryngectomy. The nurse removes the client's NG tube and initiates oral feedings. Which of the following statements should the nurse make?
"It is no longer possible for you to choke on or aspirate food."
A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client?
A room with air exhaust directly to the outdoor environment
A nurse is monitoring a client who is postoperative following a thyroidectomy. Which of the following data should the nurse identify as the priority to monitor?
Airway patency
A nurse is caring for a client who has Cushing's syndrome. Which of the following interventions should the nurse expect to perform? (Select all that apply.)
Assess blood glucose level Assess for neck vein distention daily weight
A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take?
Elevate the head of the bed 20°.
A nurse is assessing a client who is admitted for elective surgery and has a history of Addison's disease. Which of the following findings should the nurse expect?
Hyperpigmentation
A nurse is caring for a client who has Cushing's syndrome. The nurse should recognize that which of the following are manifestations of Cushing's syndrome? (Select all that apply.)
Moon face Purple striations Buffalo hump
A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?
oliguria
A nurse is caring for a client who is postoperative and whose respirations are shallow and 9/min. Which of the following acid-based imbalances should the nurse identify the client as being at risk for developing initially?
respiratory acidosis
A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take?
Reposition the client.
A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take?
Keep the drainage system below the level of the client's chest at all times.
A nurse in the PACU is assessing a client who has an endotracheal tube (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?
Movement of the ET tube into the right main bronchus
A nurse is caring for a client who is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?
Verify that the suction regulator is on and check the tubing for leaks.
