ATI MED SURG

1. A nurse is providing teaching to a client who is scheduled for a sigmoid colon resection w/ colostomy. Which of the following statements by the client indicates a need for further teaching? a. "Because most of my colon is still intact & functioning, my stool will be formed" b. "My stoma will appear large @ 1st, but it will shrink over the next several weeks" c. "My colostomy will begin to function in 2-6 days after surgery" "I'll consume a soft diet after surgery"

"I'll consume a soft diet after surgery"

57. A nurse is teaching a client how to perform range-of-motion exercises of the wrist. To perform adduction, which of the following instructions should the nurse include? a. "W/ your palm facing down, move your wrist sideways toward your thumb" b. "Move your palm toward the inner part of your FA" c. "W/ your palm facing down, move your wrist sideways toward you little finger" d. "Bring the back of your hand as far back toward the wrist as you can"

"W/ your palm facing down, move your wrist sideways toward your thumb"

2. A nurse is teaching a client who has persistent cancer pain about the adverse effects of opioids. Which of the following statements should the nurse include in the teaching? a. "Opioids do not relieve pain w/o causing severe adverse effects" b. "Physical dependence is not the same as addiction" c. "Tolerance typically means that the med will no longer be effective" "The most common adverse effect is respiratory depression w/ prolonged use"

. "Physical dependence is not the same as addiction"

1. An emergency nurse is assessing a client who has a new traumatic brain injury. The nurse observes extension of the client's arms & legs, pronation of the arms, & plantar flexion of the feet. Which of the following action is the nurse's priority? a. Monitor urinary output b. Administer an osmotic diuretic c. Provide supplemental O2 Initiate seizure precautions

. Provide supplemental O2

1. A nurse is caring for a client who has manifestations of acute tubular necrosis (ATN) following a kidney transplantation. Which of the following interventions should the nurse anticipate for this client? (SATA) a. HD b. Biopsy c. Immunosuppression d. Balloon angioplasty Surgical repair

.A. HD b. Biopsy c. Immunosuppression

60. A charge nurse is observing a newly licensed nursed administer an IV med to a client who has an implanted venous access port. Which of the following observations requires interventions by the charge nurse? a. A dressing is not applied to the port site after use b. A 22-gauge non-coring needle is used to access the port c. Blood return is noted prior to administering the med d. A solution of 5 mL Heparin 1,000 units/mL has been prepared

A solution of 5 mL Heparin 1,000 units/mL has been prepared

46. A nurse is assessing a client who has peripheral vascular disease & a venous ulcer on the right ankle. Which of the following findings should the nurse expect in the client's affected extremity? a. Absent pedal pulses b. Ankle swelling c. Hair loss d. Skin atrophy

Ankle swelling

1. A nurse is monitoring the ECG of a client who has hypocalcemia. Which of the following findings should the nurse expect? a. Flattened T waves b. Prolonged QT intervals c. Shortened QT intervals Widened QRS complexes

B. Prolonged QT Intervals

44. A nurse is talking w/ a group of women @ a community center about the current recommendations for early detection of breast cancer. The nurse should explain which of the following option? a. Begin monthly breast self-examination @ age 40 b. Have a clinical breast examination each yr. after age 30 c. Begin annual mammogram @ age 40 d. Have breast MRI q5 yrs. after 50

Begin annual mammogram @ age 40

41. A nurse is assessing for disseminated intravascular coagulation (DIC) in a client who has septic shock s/t an untreated foot wound. Which of the following findings should the nurse expect? (SATA) a. Bradycardia b. Bleeding @ the ventricular site c. Petechiae on the chest & arms d. Flushed, dry skin

Bleeding @ the ventricular site Petechiae on the chest & arms

52. A nurse is assessing a client who has cholecystitis. Which of the following findings should the nurse expect? a. Blumberg's sign ( rebound tenderness) b. Ascites ( chronic pancreatitis or pancreatic cancer) c. GI bleeding ( pancreatic cancer) d. Kehr's sign ( indicative for liver trauma)

Blumberg's sign ( rebound tenderness)

53. A nurse is implementing cold therapy for a client who has ankle sprain. Which of the following actions should the nurse take? a. Apply a cold pack to the edematous area b. Check capillary refill before applying an ice pack to the affected area c. ½-fill an ice pack w/ crushed ice d. Apply an ice pack for 60 min. intervals

Check capillary refill before applying an ice pack to the affected area

47. A nurse in an ED is assessing a client who sustained a fall off of a roof. Which of the following findings should the nurse identify as an indication of a basilar skull fracture? a. Depressed fracture of the forehead b. Clear fluid coming from the nares c. Motor loss on 1 side of the body d. Bleeding from the top of the scalp

Clear fluid coming from the nares

1. A nurse is planning care for a client who has AIDs & has developed stomatitis. Which of the following interventions should the nurse include in the plan of care? a. Rinse the mouth w/ CHG solution q2h b. Limit fluid intake w/ meals c. Provide oral hygiene w/ a firm-bristled toothbrush after each meal D. Avoid salty foods

D. Avoid salty foods

1. A nurse is completing an assessment for a client who has a h/o unstable angina. Whichc of the following findings should the nurse expect? a. Chest pain is relieved soon after resting b. Nitroglycerin relieves chest pain c. Physical exertion does not precipitate chest pain D. Chest pain lasts for longer than 15 mins

D. Chest pain lasts for longer than 15 min

1. A nurse is assessing a client who has Kaposi's sarcoma. Which of the following findings should the nurse expect? a. Nonproductive cough, fever, & SOB b. Lesions on the retina that produce blurred vision c. Onset of progressive dementia D. Reddish-purple skin lesionD. Reddish-purple skin lesionss

D. Reddish-purple skin lesions

a. 2. A nurse is assessing a client who sustained superficial partial-thickness & deep partial-thickness burns 72 hrs. ago. Which of the following findings should the nurse report to the provider? a. Edema in the burned extremities b. Severe pain @ the burn sites c. Urine output of 30 mL/hr D. Temp. of 39.1oC (102.4oF)

D. Temp. of 39.1oC (102.4oF)

32. A nurse is caring for a client who has type 1 DM & a capillary blood glucose reading of 48 mg/dL. Which of the following findings should the nurse expects? a. Kussmaul respirations b. Diaphoresis c. Decreased skin turgor d. Ketonuria

Diaphoresis

29. A nurse is caring for a client who is 2 days postoperative. Which fo the following indicates that the client is developing an infection? a. Temp. 37.8oC (100oF) b. Erythema @ the incision site c. WBC 9,000/mm3 d. Pain reported as 6 on a scale of 0 to 10

Erythema @ the incision site

31. A nurse teaching a female client w/ a new dx of SLE about factors that can trigger an exacerbation of SLE. The nurse should determine that the client requires further teaching if she identifies which of the following as an exacerbation factor? a. Exercise b. Pregnancy c. Infection d. Sunlight

Exercise

45. A nurse is preparing a client for a bronchoscopy. Which of the following actions should the nurse take? (SATA) a. Explain that the client will receive sedation & will not remember the procedure b. Verify that the client understands the purpose & nature of the procedure c. Offer the client sips of clear liquids until 1 hr. before the procedure d. Obtain a pre-procedural sputum specimen e. Instruct the client to keep his neck in a neutral position

Explain that the client will receive sedation & will not remember the procedure Verify that the client understands the

30. A nurse is caring for a client who had a CVA. The client appears alert & engaged during a visit but does not respond verbally to questions. The nurse should doc. this as which of the following alterations? a. Expressive aphasia b. Dysarthria c. Receptive aphasia d. Dysphagia

Expressive aphasia

51. A nurse is monitoring a newly licensed nurse who is caring for a client. The client has active pulmonary tuberculosis, was placed on airborne precautions, & is scheduled for a CXR. The nurse should instruct the newly licensed nurse to take which of the following actions? a. Have the client wear a surgical mask b. Wear a gown for protection from the client's infection c. Ask the radiology staff to perform a portable CXR in the client's room d. Place an N-95 respirator on the client

Have the client wear a surgical mask

55. 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 HR @ the same time each day" b. "I don't have to take my anti-HTN meds now that I have 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 oven when it is on"

I should check my HR @ the same time each day"

59. A nurse is assessing a client who is 12 hr. postoperative following an open chloecystctomy. Which of the following findings should the nurse report to the provider? a. Hypoactive bowel sounds b. Indwelling urinary catheter output of 25 mL/hr c. HR of 96 bpm d. Serous drainage @ the surgical incision site

Indwelling urinary catheter output of 25 mL/hr

1. A nurse is caring for a client who experienced a traumatic head injury & had an IV catheter (Ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications r/t the ventriculostomy? a. HA b. Infection c. Aphasia d. HTN

Infection

58. A nurse is caring for a client who is NPO & has an NG tube to suction. When the client reports nausea, which of the following actions should the nurse take? a. Irrigate the tube w/ NS b. Provide oral hygiene c. Clamp the tube for 30 min d. Increase the amount of suction

Irrigate the tube w/ NS

54. A nurse is caring for a client following a stroke. Which of the following actions should the nurse take 1st? a. Obtain coagulation lab studies from the client b. Apply pneumatic compression boots to the client c. Request a referral for a SLP d. Keep the client NPO

Keep the client NPO

50. A nurse is removing PPE after performing a procedure for a client who requires isolation precautions? Which of the following items of PPE should the nurse remove 1st? a. Gloves b. Gown c. Eyewear d. Mask

MASK

56. A nurse is caring for a client who has a percutaneous endoscopic gastrostomy (PEG) tube & is receiving intermittent feedings. Prior to initiating the feeding, which of the following actions should the nurse take 1st? a. Flush the tube w/ water b. Place the client in the semi-fowler's position c. Cleanse the skin around the tube site d. Aspirate the tube for residual contents

Place the client in the semi-fowler's position

48. A nurse is caring for a client who has DI. For which of the following findings should the nurse monitor? a. Proteinuria b. Oliguria c. Polyuria d. Glycosuria

Polyuria

a. 2. A nurse is caring for a client during the 1st 72 hr. following a cerebrovascular accident (CVA). Which of the following actions should the nurse take? a. Turn the client's head to the side w/ the HOB elevated 60o b. Place the head of the bed flat w/ pillows under the client's neck & feet c. Elevate the HOB 25o to 30o w/ the client in a neutral midline position Position the client in a dorsal recumbent position w/ pillow under the head & knees

Position the client in a dorsal recumbent position w/ pillow under the head & knees

61. A nurse is providing d/c instructions to a client who is postoperative following surgical excision of a basal cell carcinoma. Which of the following findings should the nurse include as an indication of a mole's potential malignancy? a. Ulceration b. Blanching of surrounding skin c. Dimpling d. Fading of color

Ulceration

49. A client is being d/c'd home w/ O2 therapy delivered through a NC. Which of the following instructions should the nurse provide to the client & family members? a. Used battery-operated equipment for personal care b. Apply mineral oil to protect the facial skin from irritation c. Remove the television set from the client's bedroom d. Wear cotton clothing to avoid static electricity

Wear cotton clothing to avoid static electricity

1. A nurse is examining ECG of a client who has hyperkalemia. Which of the following ECG changes should the nurse expect? a. Elevated ST segments b. Absent P waves c. Depressed ST segments d. Varying PP intervals

a. Elevated ST segments

1. A nurse is teaching a client who has CAD about the difference b/w angina pectoris & MI. Which of the following should the nurse identify as indications of MI? (SATA) a. N/V b. Diaphoresis & dizziness c. Chest & left arm pain that subsides w/ rest d. Anxiety & feelings of doom

a. N/V b. Diaphoresis & dizziness d. Anxiety & feelings of doom

37. A nurse is teaching a newly licensed nurse about caring for a client who is scheduled for an esophagogastric balloon tamponade tube to treat bleeding esophageal varices. Which of the following pieces of info should the nurse include in the teaching? a. The client will be placed on mechanical ventilation prior to this procedure b. The tube will be inserted into the client's trachea c. The client will receive a bowel preparation w/ cathartic prior to this procedure d. The tube allows the application of a ligation band to the bleeding varices

a. The client will be placed on mechanical ventilation prior to this procedure

1. A nurse is assessing a client w/ a closed head injury who has received mannitol for manifestation of ICP. Which of the following findings indicates that the med is having a therapeutic effect? a. The client's serum osmol is 310 mOsm/L b. The client's pupils are dilated c. The client's HR is 56 bpm d. The client is restless

a. The client's serum osmol is 310 mOsm/L

1. A nurse is monitoring a client for reperfusion following thrombolytic therapy to treat acute MI. Which of the following indicators should the nurse identify to confirm reperfusion? a. Ventricular dysrhythmias b. Appearance of Q waves c. Elevated ST segments Recurrence of chest pain

a. Ventricular dysrhythmias

1. A nurse is preparing a client who is scheduled to have an arthroscopy the following day. Which of the following statements indicates that the client understands the pre-procedure teaching? a. "I have to keep my leg straight throughout the whole procedure" b. "The doctor will be able to see if I have signs of RA" c. "I should expect to stay overnight until I can walk around" d. "I'll have a scar that will be about an inch long"

b. "The doctor will be able to see if I have signs of RA"

1. A nurse is providing edu. to a client who is to undergo an EEG the next day. Which of the following info should the nurse include in the teaching? a. "Do no wash your hair the morning of the procedure" b. "Try & stay awake most of the night prior to the procedure" c. "The procedure will take approx. 15 mins" "You will need to lie flat for 4 hrs. after the procedure"

b. "Try & stay awake most of the night prior to the procedure

A nurse is caring for a client who is postprocedural following a lumbar puncture & reports a throbbing HA when sitting upright? Which of the following actions should the nurse take? SATA a. Use of GCS scale to assess the client b. Assist the client into a supine position c. Administer an opioid analgesic d. Encourage the client to increase PO fluid intake Instruct the client to perform coughing & deep breathing

b. Assist the client into a supine position d. Encourage the client to increase PO fluid intake

38. A nurse is preparing an in-service presentation about the management of MI. Death following MI is often a result of which of the following complications? a. Cardiogenic shock b. Dysrhythmias c. HF d. Pulmonary edema

b. Dysrhythmias

1. A nurse is reviewing the lab results of a lumbar puncture for a client who has manifestations of bacterial meningitis. Which of the following findings should the nurse expect? a. Elevated glucose b. Elevated protein c. Presence of TBCs Presence of D-dimer

b. Elevated protein

1. A nurse is caring for a client who is taking streptomycin. Which of the following meds increases the client's risk of developing ototoxicity when taken w/ streptomycin? a. Cefoxitin b. Furosemide c. Naproxen d. Amphotericin B

b. Furosemide

1. A nurse is preparing an in-service program about the stages of AKI. Which of the following piees of info should the nurse include about prerenal azotemia? a. Prerenal azotemia begins prior to the onset of symptoms b. Interference w/ renal perfusion causes renal azotemia c. Prerenal azotemia is irreversible, even in early stages Infections & tumors cause prerenal azotemia

b. Interference w/ renal perfusion causes renal azotemia

1. nurse is planning care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan of care? a. Restrict fluids to 1,000 mL per day b. Measure the client's abd girth daily c. Check IV sites q4h for bleeding Administer an enema PRN for constipation

b. Measure the client's abd girth daily

34. A nurse is examining the ECG of a client who has frequency premature ventricular contractions (PVCs). Which of the following QRS changes should the nurse expect to see on the client's ECG? a. Narrower than usual QRS complexes b. Much greater amplitude than the usual QRS complexes c. Same polarity as the usual QRS complexes d. Immediate resumption of the usual rhythm

b. Much greater amplitude than the usual QRS complexes

1. A nurse is caring for a client who is experiencing autonomic dysreflexia due to a C5 SCI. After checking the client's VS, which of the following actions should the nurse perform nxt? a. Administer nifedipine b. Place the client in a high-fowler's position c. Check for urinary retention Check for a fecal impaction

b. Place the client in a high-fowler's position

1. A nurse is preparing to administer an IM injection for a client. Which of the following factors should the nurse identify as a potential contraindication to administering the med via the IM route? a. The med is a depot preparation b. The client is taking an anticoagulant c. The med is a particulate suspension The client has been vomiting

b. The client is taking an anticoagulant

a. 2. A nurse is caring for a semiconscious client who had a small-bore NG tube placed yesterday for the administration of enteral feeding? Which of the following methods should the nurse use to verify correct tube placement? (SATA) a. Auscultate injected air b. Verify the initial XR examination c. Measure the length of the exposed tube d. Determine the pH of aspirated fluid Check the aspirated fluid for glucose

b. Verify the initial XR examination c. Measure the length of the exposed tube d. Determine the pH of aspirated fluid

a. 2. A nurse is teaching a client who has polycythemia vera about self-care measures. Which of the following interventions should the nurse include? a. "Drink @ least 1 L of fluid each day" b. "Continuously wear support hose" c. "Elevate your legs when sitting" "Use dental floss daily"

c. "Elevate your legs when sitting"

1. A nurse is assessing a client who has fractured left femur & is in skeletal traction. Which of the following findings should the nurse report to the provider? a. Ecchymosis of the thigh b. Serous drainage @ the pin site c. Chest petechiae Muscle spasms in the left leg

c. Chest petechiae

a. 2. A nurse is preparing a client who has a brain tumor for a CT scan. Which of the following factors affects the manner in which the nurse will prepare the client for the scan? a. No food or fluids consumed for 4 hrs. b. Difficulty recalling recent events c. Development of hives while eating shrimp Paresthesia in both hands

c. Development of hives while eating shrimp

33. A nurse is caring for a client who has a major burn injury & is experiencing 3rd spacing. Which of the following fluid or electrolyte imbalances should the nurse expect? a. Hypokalemia b. Hypernatremia c. Elevated hct d. Decreased HgB

c. Elevated hct

1. A nurse is caring for a client who had a left lower lobectomy to treat lung cancer. Which of the following factors will have a significant impact on the plan of care for this client? a. The client will need intensive smoking-cessation edu. b. After surgery, the prognosis for clients w/ lung cancer is usually good c. Lung cancer usually has metastasized before the client presents w/ symptoms O2 therapy is ineffective following a lobectomy

c. Lung cancer usually has metastasized before the client presents w/ symptoms

1. A nurse is caring for a client w/ C. diff. who has contact-isolation precautions in place. Which of the following actions should the nurse perform? a. Instruct visitors to maintain a distance of @ least 1 m (3 ft) from the client b. Wash hands w/ antimicrobial soap after leaving the client's room c. Use dedicated equipment for the client Keep the doors to the client's room closed @ all times

c. Use dedicated equipment for the client

1. 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 irrigate b. Client reports bladder spasms c. Viscous urinary output w/ clots Reports of strong urge to urinate

c. Viscous urinary output w/ clots

1. A nurse is teaching a client who has a new dx of primary open-angle glaucoma (POAG). Which of following pieces of info should the nurse include in the teaching? (SATA) a. Lost vision can improve w/ eye drops b. Administer eye drops PRN for vision loss c. Glasses will be necessary to correct the accompanying presbyopia d. Driving can be dangerous due to the loss of peripheral vision E. Laser surgery can help re-establish the flow of aqueous humor

d. Driving can be dangerous due to the loss of peripheral vision E. Laser surgery can help re-establish the flow of aqueous humor

1. A nurse is providing teaching to a client who has a new dx of MG. Which of the following pievecs of info should nurse include? a. Use enemas to treat constipation caused by daily meds b. Take a hot bath when muscles ache c. Eat a low-cal. diet d. Set an alarm to ensure med dosages are taken on timed. Set an alarm to ensure med dosages are taken on time

d. Set an alarm to ensure med dosages are taken on time