ATI Medical Surg Custom II

A nurse is assessing a client who has right ventricular failure. Which of the following findings should the nurse expect?

Hepatomegaly

A nurse is teaching a client who has chronic kidney failure about planning a low-protein diet. The client states, "Why do I have to be concerned about protein?" Which of the following responses should the nurse make?

"A low-protein diet reduces the risk for uremia."

A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?

"DIC is caused by abnormal coagulation involving fibrinogen."

A nurse is caring for a client who is being treated with a cesium implant. The client tells the nurse, "I feel so isolated and alone in this room." After acknowledging the client's feelings of loneliness, which of the following responses should the nurse provide?

"Do you have a cell phone you can talk to friends and family on?"

A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client?

"Have you had a recent influenza infection?"

A nurse is teaching a client who is scheduled for a CT scan of the head with contrast. Which of the following statements by the client indicates a need for further teaching?

"I can take my morning dose of metformin."

For each client finding, click to specify if the finding is consistent with Parkinson's disease, stroke, and/or multiple sclerosis. Each finding can support more than one disease process.

-Facial symmetry is consistent with stroke.-Hypertension is consistent with stroke.-Cognitive function is consistent with Parkinson's disease, stroke, and multiple sclerosis.-Speech is consistent with Parkinson's disease, stroke, and multiple sclerosis.-Mobility is consistent with Parkinson's disease, stroke, and multiple sclerosis

A nurse at a blood donation center is screening clients for blood donation. The nurse should identify that which of the following clients must reschedule donation?

A client who has an oral temperature of 37.8° C (100° F)

A nurse is preparing to administer medications to four clients. The nurse should administer medications to which of the following clients first?

A client who has renal failure, a serum potassium of 5.8/mEq/L, and is prescribed sodium polystyrene sulfonate

A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse expect?

Acetone odor to breath

A nurse is admitting a client to a medical-surgical unit following a fall at home.

Administer an IV fluid bolus is anticipated. The client has manifestations of dehydration, such as tachycardia, decreased urine output, and an elevated urine specific gravity. Obtain an x-ray of the right hip is anticipated. The client has right hip pain after falling and is at risk for a hip fracture. Obtain the client's weight is anticipated. The client has a history of heart failure and manifestations of dehydration; therefore, the nurse should anticipate obtaining the client's weight to monitor the client's fluid balance. Administer supplemental oxygen is nonessential. The client has an oxygen saturation on room air that is within the expected reference range. Administer spironolactone is contraindicated. Spironolactone is a potassium-sparing diuretic that is contraindicated in clients who have hyperkalemia. Administer an iron supplement is a nonessential. The iron supplement is administered for iron-deficiency anemia. The client's Hgb and Hct levels are within the expected reference range; therefore, the iron supplement is non-essential.

A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the following times?

As soon as the nurse can prepare the client and the administration set

A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia?

Atropine

A nurse is caring for a client who is 2 days postoperative following a small bowel resection.

Blood pressure is incorrect Incisional pain is correct

A nurse is performing cardiopulmonary resuscitation (CPR) for an adult client who is unresponsive. The nurse should evaluate the client's circulation by palpating which of the following pulses?

Carotid

A nurse enters a client's room and finds him unresponsive. After notifying the rapid response team, which of the following actions should the nurse take first?

Check for a carotid pulse.

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 reviewing the laboratory test results of an older adult client who is scheduled for elective removal of uterine fibroid tumors. When noting an erythrocyte sedimentation (ESR) rate of 28 mm/hr, the nurse should take which of the following actions?

Continue reviewing the preoperative test results.

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?

Dehydration

A nurse is talking with a client who is about to undergoing radionuclide imaging. The nurse should explain that the procedure will help do which of the following?

Detect damage to the heart muscle.

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?

Encouraging the client to drink 2 to 3 L of water daily

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 reviewing the laboratory values of a client who is at risk for disseminated intravascular coagulopathy. Which of the following values should the nurse report to the provider?

Fibrinogen 85 mg/dL

A nurse is caring for a client immediately following a hemodialysis treatment. For which of the following manifestations will the nurse administer a PRN dose of phenytoin?

Headache, restlessness

A nurse is assessing a client who has thyrotoxicosis after taking too high of a level of levothyroxine. Which of the following manifestations should the nurse expect?

Heat intolerance

A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering?

Heparin

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 assessing a client who has fluid volume deficit. The nurse should expect which of the following findings?

Increased BUN

A nurse is assessing a client who has a left lower arm fracture. Which of the following findings indicates impaired venous return in the client's affected arm?

Increasing edema

A nurse is caring for a client who has AIDS.

Infection is correct. CD4-T-cell count is correct.

A nurse is preparing to turn a client who is obese following a spinal fusion. The nurse should plan to use which of the following techniques to turn this client?

Log roll

A nurse is planning care for a client who is 1 day postoperative following spinal fusion. Which of the following actions should the nurse include?

Log roll the client every 2 hr.

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 developing a plan of care for a client who has a fracture to achieve the outcome of functional healing. To assist in meeting this goal, which of the following nursing interventions is the highest priority?

Maintain immobilization and alignment.

A nurse is teaching a client who has hepatitis A. Which of the following information should the nurse include?

Manifestations of the virus are similar to flu-like symptoms.

A nurse is caring for a 67-year old male client who reports abdominal pain and vomiting for one week.

Metabolic alkalosis is correct Nasogastric suctioning is correct

A nurse is caring for a client who has an intracranial aneurysm and requires aneurysm precautions. Which of the following interventions should the nurse take?

Minimize environmental stimuli.

A nurse in a provider's office is assessing a client who reports occasional atypical chest pain, palpitations, and exercise intolerance. On auscultation, the nurse notes a systolic click. The nurse should recognize this finding as a manifestation of which of the following conditions?

Mitral valve prolapse

A nurse is caring for a client following an abdominal surgery. The client has a prescription for dressing changes every 4 hr and as needed. Which of the following objects should the nurse use to reduce skin irritation around the incision area?

Montgomery straps

A nurse is assessing a client who has a hip fracture. Which of the following findings should the nurse expect?

Muscle spasms

A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?

Obtain a 12-lead ECG.

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 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 completing a physical assessment of a client who has early osteoarthritis. Which of the following manifestations should the nurse expect?

Pain worsens with activity

A nurse is admitting a client who is having an exacerbation of his asthma. When reviewing the provider's orders, the nurse recognizes that clarification is needed for which of the following medications?

Propranolol

A nurse is caring for a client who has chronic glomerulonephritis. The nurse should expect to find a decrease in which of the following serum laboratory values?

RBC

A nurse is assessing a client who has intravenous therapy-related phlebitis. The nurse uses the Infusion Nurses Society's phlebitis scale to assess the severity of phlebitis and documents the client's phlebitis as a grade level 1. Which of the following assessment findings correlates with a grade level of 1?

Redness at the intravenous access site with pain

A nurse is caring for a client who has HIV.

Sepsis and malnutrition are correct

A nurse is assessing a client who is taking chlorothiazide sodium. The nurse recognizes which of the following as a manifestation of hypokalemia?

Shallow respirations

A nurse is caring for a client involved in a suspected bioterrorism event involving exposure to cutaneous anthrax. Which of the following manifestations should the nurse anticipate?

Skin lesions with pruritus

A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority?

Suction saliva from the client's mouth.

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 caring for a 45-year-old client in the emergency department.

The nurse should obtain an echocardiogram and obtain a prescription for an NSAID such as ibuprofen because the client is most likely experiencing pericarditis due a respiratory infection. The nurse should monitor the client's pain as well as for pulsus paradoxus (a systolic blood pressure increase of > 10 mm Hg during inspiration) which is a manifestation of cardiac tamponade and is a medical emergency.

A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a myocardial infarction? (Select all that apply.)

Troponin I Troponin T СРК Myoglobin

A nurse is caring for a group of clients in an infectious disease unit. The nurse should wear an OSHA-approved N95 respirator mask when caring for a client with which of the following infectious diseases?

Tuberculosis

A nurse is caring for a client in the emergency department.

Upon recognizing and analyzing the client cues of anemia, jaundice, and acute vaso-occlusive symptoms, the nurse's priority hypotheses is that this client is most likely experiencing sickle cell anemia. It is important to generate solutions and take actions that will improve anemia and reduce the sickling of blood cells. Therefore, the nurse should draw a type and cross match and administer oxygen to increase tissue perfusion and improve gas exchange, thereby, reducing sickling of red blood cells. To evaluate these interventions, the nurse should monitor the client's hydration status and their abdomen for splenic tenderness which may indicate damage from episodes of ischemia and hypoxia.

A nurse is planning care for a client who is to start receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include in the plan of care?

Use a 1.2 micron filter when infusing TPN with fat emulsions added.

A nurse is assigned to care for a client diagnosed with autoimmune or idiopathic thrombocytopenic purpura (ITP). When reviewing the client's plan of care prior to caring for the client, the nurse should recognize that the priority concern in caring for the client is to monitor for

bleeding.

A nurse is assessing a client who had left femoral cardiac angiography. Identify where the nurse will palpate to assess the most distal pulse on the affected side. (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)

left pedal pulse

A nurse is caring for a 33-year-old client on a medical-surgical unit.

place client NPO Obtain prescription for a glucocorticoid Ulcerative collitis ESR & WBC count levels

A nurse is caring for a client who has meningitis, a temperature of 39.7° C (103.5° F), and is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must carefully be observed for which of the following complications?

shivering

A nurse is teaching a client about risk factors for skin cancer. Which of the following statements by the client indicates an understanding of the teaching?

"I should apply sunscreen prior to going outside, even in the winter months."

A nurse is teaching with a client about taking high doses of oral glucocorticoids for an extended period of time to treat rheumatoid arthritis. Which of the following instructions should the nurse include in the teaching?

"Monitor for compression fractures of the back and neck."

A nurse is caring for the client who has Ménière's disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make?

"Please ring for assistance when you wish to get out of bed."

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 nurse is preparing to perform a 12-lead electrocardiogram. Which of the following instructions should the nurse provide to the client?

"Try to remain still once I have attached the gel pads."

A nurse is providing discharge instructions to a client following a cardiac catheterization. Which of the following information should the nurse include?

"You will notice a small hematoma at the incision site."

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 nurse is admitting a client who has sustained severe burn injuries in a grease fire. The nurse shades in a diagram indicating the burned surface areas. Using the Rule of Nines, the nurse should estimate that the client has burned what percentage of body surface area? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

31.5

A nurse on a medical-surgical unit is caring for a client.

The nurse should medicate the client for bladder spasms and irrigate the urinary catheter because the client is most likely experiencing an obstructed urinary catheter. Clots and tissue debris can pass through and block the flow of urine through the catheter. If the urinary catheter becomes obstructed, the nurse should irrigate the indwelling catheter to maintain the flow of irrigation and urine. The nurse should also medicate the client for bladder spasms that can occur as a result of obstruction of the catheter. The nurse should closely monitor the client's urine output to ensure that further obstruction to the catheter does not occur. The nurse should also frequently monitor the client's blood pressure and pulse to detect if bleeding is occurring because this is a risk factor of a TURP procedure. The nurse should monitor the client's hemoglobin and hematocrit levels and urine output because a complication of a transurethral resection of the prostate is bleeding from bladder spasms or movement. Also, the nurse should monitor the color, consistency, and amount of the client's output to detect any further obstruction and bleeding.

A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the troponin levels report, the client asks what this blood test will show. Which of the following explanations should the nurse provide the client?

Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart.

A nurse is developing a teaching plan for a client who has psoriasis. Which of the following information should the nurse include in the plan?

Use bath oils to soften and soothe the skin.

A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse plan to implement?

Vitamin B12 injections

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 who has uncontrolled type 1 diabetes mellitus. Which of the following findings should the nurse expect?

Weight loss