ATI - Medical Surgical

b c e

A client is admitted to the emergency department after reporting acute chest pain radiating down the left arm. The client appears anxious, dyspneic, and diaphoretic. Which laboratory studies would the nurse anticipate? Select all that apply a. Blood urea nitrogen (BUN) b. Myoglobin c. Creatine kinase (CK) d. Hemoglobin and hematocrit (HCT) e. Troponin T and troponin I f. Serum glucose

b c f

A client is prescribed lisinopril for the treatment of hypertension. The client asks a nurse about possible adverse effects. Which common adverse effects of angiotensin-converting enzyme (ACE) inhibitors would the nurse include in the teaching? Select all that apply a. Impotence b. Hypotension c. Dry cough d. Hyperglycemia e. Constipation f. Headache

c d e f

A client with a suspected pulmonary embolus is brought to the emergency department stating shortness of breath and chest pain. Which additional signs and symptoms are anticipated? Select all that apply a. Frothy sputum b. Bradycardia c. Tachycardia d. Irregular heart beat e. Blood-tinged sputum f. Anxiety

a b f

A client with chronic obstructive pulmonary disease (COPD) is being evaluated for a lung transplant. Which initial assessment data would the nurse anticipate? Select all that apply a. Unintended weight loss b. Barrel chest c. Fever d. Shortened expiratory phase e. Decreased respiratory rate f. Dyspnea on exertion

a b d

A fireman is admitted with superficial skin wounds and a sprained back following an intense fire. No respiratory concerns are verbalized. Nearly 24 hours after admission, the fireman reports dyspnea, a harsh cough, and hoarseness. Which nursing interventions would the nurse add to the plan of care? Select all that apply a. Auscultate the lungs for adventitious breath sounds. b. Monitor for increased anxiety levels. c. Prepare the chest for chest tube insertion. d. Assess for increased pulse rate. e. Monitor for fever.

c d e f

A nurse assesses a client with suspected bacterial meningitis. Which documented findings of meningeal irritation suggest this diagnosis? Select all that apply a. Tinnitus b. Babinski's reflex c. Positive Kernig's sign d. Positive Brudzinski's sign e. Photophobia f. Nuchal rigidity

a d f

A nurse is assessing a client's extraocular eye movements as part of evaluating neurological functioning. This documents the status of which cranial nerves? Select all that apply a. Oculomotor (III) b. Trigeminal (V) c. Acoustic (VIII) d. Abducens (VI) e. Optic (II) f. Trochlear (IV)

a c f

A nurse is awaiting the arrival of a client from the emergency department with a diagnosis of anterior wall myocardial infarction. In caring for this client, the nurse would be alert for which signs and symptoms of left-sided heart failure? Select all that apply a. Dyspnea b. Hepatomegaly c. Crackles d. Jugular vein distention e. Skin tenting f. Tachycardia

a b c e

A nurse is caring for a client with Raynaud's phenomenon secondary to systemic lupus erythematosus (SLE). Which of the client statements demonstrates an understanding of the nurse's teaching about this disorder? Select all that apply a. "My hands get pale and bluish and feel numb and painful when I'm really stressed." b. "I probably got this disorder because I am also diagnosed with lupus." c. "This problem is caused by a temporary lack of circulation in my hands." d. "I don't need to report any other skin problems with my fingers or hands to my health care provider." e. "I will have to discuss medication which might treat this problem with my health care provider." f. "I can't continue to wash dishes and do my cleaning because of this problem."

b c d f

A nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above T5, and blood pressure of 174/100 mm Hg. The client reports a severe, pounding headache. Which nursing interventions would be appropriate for this client? Select all that apply a. Use a fan to reduce diaphoresis. b. Loosen constrictive clothing. c. Assess for bladder distention and bowel impaction. d. Administer antihypertensive medication as ordered. e. Administer morphine as ordered. f. Elevate the head of the bed to 90°.

a c f

A nurse is caring for a client with a new prescription of digoxin. Which client statement would require further teaching about digoxin? Select all that apply a. "I understand that I will need annual blood work to check therapeutic levels." b. "I will take my pulse before each dose of digoxin." c. "I will take the digoxin with my antacids at night." d. "I will take the digoxin at 9 AM daily." e. "I will notify my health care provider if experiencing increased fatigue or muscle weakness." f. "If I forget a dose, I will catch up by doubling the next dose."

a d f

A nurse is caring for a client with a traumatic injury and developing tension pneumothorax. Which assessment data would be of concern? Select all that apply a. Decreased cardiac output b. Flattened neck veins c. Bradypnea d. Tracheal deviation to the unaffected side e. Tracheal deviation to the affected side f. Hypotension

a c e f

A nurse is caring for a client with history of heart failure and presenting with symptoms indicating a pulmonary embolism. The nurse documents admission findings of sudden shortness of breath, chest pain, and immobility. Which nursing diagnoses are admission priorities? Select all that apply a. Anxiety related to breathlessness b. Disturbed sleep pattern related to restlessness in the night c. Activity intolerance related to inadequate oxygenation d. Impaired nutrition: less than body requirements related to anorexia e. Risk for decreased cardiac output related to failure of the left ventricle f. Ineffective breathing pattern related to hypoxia

a b

A nurse is comparing the neurological status of a client who suffered a head injury with the status on the previous shift. Using the Glasgow Coma Scale, the nurse determines that the client's score has changed from 11 to 15. Which responses did the nurse assess in this client? Select all that apply a. Spontaneous eye opening b. Orientation to person, place, and time c. Incomprehensible sounds d. Pain localization e. Unequal pupil size f. Tachypnea, bradycardia, and hypotension

b c e

A nurse is counseling a client about risk factors for hypertension. While reviewing the client's history, which information is consistent with the diagnosis of primary hypertension? Select all that apply a. Head injury b. Obesity c. Stress d. Glomerulonephritis e. High intake of sodium or saturated fat f. Hormonal contraceptive use

d e f

A nurse is evaluating a client with primary pulmonary hypertension for a heart-lung transplant. Which medication treatment would the nurse anticipate to be included in the plan of care? Select all that apply a. Sulfonamides b. Antihistamines c. Aminoglycosides d. Vasodilators e. Oxygen therapy f. Diuretics

d

A nurse is monitoring a client's intracranial pressure (ICP) after a traumatic head injury. The health care provider calls and asks for a report on the client's condition. Based on the documentation below, how would the nurse respond? a. "The client's ICP was elevated but now has returned to normal." b. "The client's ICP is within normal limits." c. "The client's ICP has decreased to lower than normal limits." d. "The client's ICP remains elevated."

1 3 5 6 2 4

A nurse is presenting health information at a community organization when one of the attendees passes out. The nurse assesses the attendee as being unresponsive. Indicate how the nurse would respond by placing the following actions in chronological order. 1. appoint a person to call 911 2. deliver 2 rescue breaths 3. perform chest compressions 4. check for a pulse 5. perform a head tilt-chin lift maneuver 6. check for normal breathing

a b c e

A nurse is providing discharge instructions on phenytoin to a female client with tonic-clonic seizure disorder. Which instructions would the nurse include? Select all that apply a. Monitor the body for any skin rash. b. Report any problems with walking or coordination, slurred speech, or nausea. c. Receive necessary periodic blood work. d. Maintain adequate amounts of fluid and fiber in the diet. e. Perform good oral hygiene, including daily brushing and flossing.

b c d f

The nurse has been assigned to care for the following six clients. Which clients would the nurse expect to be at risk for the development of pulmonary embolism? Select all that apply a. A client who is receiving supplemental oxygen following shoulder surgery b. A client who has undergone a total vaginal hysterectomy and is now on estrogen replacement therapy c. A client who has recently been admitted with a broken femur and is awaiting surgery d. A client who is on complete bed rest following extensive spinal surgery e. A client who has a pleural effusion secondary to infection f. A client who has a large venous stasis ulcer on the right ankle area

a d

The nurse is caring for a client who is experiencing an exacerbation of gout. When providing instruction, which dietary modifications are stressed? Select all that apply a. Eat a low-purine diet. b. Limit sodium intake to 1500mg/day. c. Limit fluid intake to no more than 1 L/day. d. Limit alcohol intake. e. Eat a high-protein diet, with at least two servings of lean meat per day.

a d e f

The nurse is caring for a client who is scheduled to undergo a computed tomography (CT) scan to assess recent symptoms of muscle weakness and tingling in the extremities. Which information would the nurse include in a preprocedural teaching plan? Select all that apply a. Throat irritation and facial flushing may occur if contrast dye is used. b. The CT scan is considered an invasive procedure, but not dangerous. c. All medications must be withheld for 12 hours prior to the procedure. d. The test may require removal of watches, bracelets or earrings. e. A contrast dye may be given before the test. f. It is necessary to report any known allergies to iodine or seafood prior to the procedure.

a e f

The nurse is caring for a senior citizen who lives alone. When evaluating the effectiveness of adding Advair (fluticasone propionate and salmeterol) to the chronic obstructive airway disease (COPD) client's medication regimen, which client statements would support symptom improvement? Select all that apply a. "I have begun walking up stairs to use the bathroom." b. "I have noted an increase in sputum production." c. "I can rely on the medication when I have an exacerbation of symptoms." d. "I seem to feel nervous and shaky making me more productive." e. "I can now push my granddaughter on the swings when she visits." f. "The nurse aide no longer comes to the house to help me bathe."

a c e f

The nurse is caring for several clients on the respiratory unit who are receiving the β-adrenergic agonist bronchodilator albuterol in the prescribed nebulizer treatments. Which side effects would the nurse expect to assess following administration? Select all that apply a. Tachycardia b. Increased tachypnea c. Anxiety d. Increased somnolence e. Insomnia f. Irritability and nervousness

a b d

The nurse is evaluating the cardiac function of a client with history of left ventricular hypertrophy and new diltiazem administration. Which client statements indicate therapeutic use of diltiazem leading to adequate cardiac functioning? Select all that apply a. "My blood pressure has been consistently in the 130/70 range." b. "I am sleeping well in the second floor bedroom." c. "In the morning, I notice 2 plus edema in my ankles." d. "I am completing all of my activities of daily living independently." e. "I am tolerating my new low-fat diet." f. "My lab results reveal a serum potassium of 3.5 mEq/L (3.5 mmol/L)."

c f

The registered nurse (RN) is assisting the licensed practical nurse (LPN) in performing a purified protein derivative (PPD) test on a nursing home resident. Which statements about this test are correct? Select all that apply a. No wheal should appear at the site following injection. b. Hold the syringe at a 45° angle to the skin. c. The preferred injection site is the ventral surface of the forearm. d. A PPD test is done to test for allergies. e. Always aspirate before injecting the PPD solution. f. The PPD test is an intradermal test.

a b c d e

While managing a client's immediate post-cardiac catheterization period, which interventions are priorities? Select all that apply a. Restrict the client to bed rest for 2 to 6 hours. b. Assess for any signs of hematoma formation c. Monitor vital signs every 15 minutes for the first hour. d. Assess the catheter insertion site every 30 minutes for 4 hours. e. Note any limb discoloration and reported numbness. f. Assess all peripheral pulses frequently.