Med Surg ATI Exam 2

a nurse in the emergency department is assessing an older adult client who has community-acquired pneumonia. which of the following findings should the nurse expect? a. unequal pupils b. hypertension c. tympany upon chest percussion d. confusion

d

a nurse is assessing a client who has COPD. the nurse should expect the client's chest to be which of the following shapes? a. pigeon b. funnel c. kyphotic d. barrel

d

a nurse is providing teaching for a client who has diabetes and a new prescription for insulin glargine. which of the following instructions should the nurse provide regarding this type of insulin? a. insulin glargine has a duration of 3-6 hours b. insulin glargine has a duration of 6-10 hours c. insulin glargine has a duration of 16-24 hours d. insulin glargine has a duration of 18-24 hours

d

a nurse is providing teaching to a client who is taking warfarin about monitoring its therapeutic effects. which of the following explanations should the nurse provide about the INR test? a. the INR also monitors heparin therapy if provider switches medication prescription b. the INR is the only test available for anticoagulant therapy monitoring c. you will only need the test twice per month d. the INR is a standardized test that eliminates the variations between laboratories reports in prothrombin times

d

a nurse is teaching a client about taking an expectorant to treat a cough. the nurse should explain that this type of medication has which of the following actions? a. reduces inflammation b. suppresses the urge to cough c. dries mucus membranes d. stimulates secretions

d

a nurse is teaching a client who has a new diagnosis of asthma. which fo the following medications should the nurse instruct the client to use to abort an acute asthma attack? a. beclomethasone b. salmeterol c. formoterol d. albuterol

d

a nurse is caring for a child who is experiencing status asthmaticus. which of the following interventions is the priority for the nurse to take? a. administer a short acting Beta 2 agonist b. obtain a peak flow reading c. administer an inhaled glucocorticoid d. determine the cause of the acute exacerbation

a

a nurse is assessing a client who has diabetes mellitus. which of the following findings is a manifestation of hypoglycemia? a. bradycardia b. cool, clammy skin c. vomiting d. fruity odor on the client's breath

b

a nurse is assessing a male client who has advanced peripheral artery disease (PAD). which of the following findings should the nurse expect? a. thin, pliable toe nails b. leg pain at rest c. hairy legs d. flushed warm legs

b

a nurse is assessing four clients on a medical unit. the nurse should identify which of the following clients as exhibiting positive manifestations of hypercortisolism? a. a client who has a butterfly rash on his face b. moon face c. a client who has a positive chvostek's sign d. a client who has muscle hypertrophy

b

a nurse is caring for a client who is 1 day postoperative following a thyroidectomy and reports severe muscle spasms of the lower extremities. which of the following actions should the nurse take? a. check the pedal pulse b. verify the most recent calcium level c. request prescription for a relaxant d. administer an oral potassium supplement

b

a nurse is planning care for a client who is postoperative following a thyroidectomy. which of the following interventions should the nurse include in the plan? a. instruct the client to deep breath every 4 hours b. check the client's voice every 2 hours c. place the head of the client's bed in the flat position d. hyperextend the client's neck

b

a nurse is providing discharge teaching to a client who has asthma and new prescriptions for cromolyn and albuterol, both by nebulizer. which of the following statements by the client indicates an understanding of the teaching? a. if my breathing begins to feel tight, I will use the cromolyn immediately b. I will be sure to take the albuterol before taking the cromolyn c. I will use both medications immediately after exercising d. I will administer the medications 10 minutes apart

b

a nurse is providing teaching to a client who has a new prescription for transdermal nitroglycerin paste. which of the following statements by the client indicates the need for further teaching a. I should measure the dosage on the supplied paper b. I should leave the patch in place until it is time for the next dose c. I should get up slowly when i stand d. I might have a headache when I first start taking this medication

b

a nurse is teaching a client who has been taking prednisone to treat asthma and has a new prescription to discontinue the medication. the nurse should explain to the client to reduce the dose gradually to prevent which of the following adverse effects? a. hyperglycemia b. adrenocortical insufficiency c. severe dehydration d. rebound pulmonary congestion

b

a nurse is assessing a client who has type 1 diabetes mellitus and finds the client lying in bed, sweating, and reporting feeling anxious. which of the following complications should the nurse suspect? a. hypoglycemia b. nephropathy c. hyperglycemia d. ketoacidosis

a

a nurse is caring for a client who develops a ventricular fibrillation rhythm. the client is unresponsive, pulseless, and apneic. which of the following actions is the nurse's priority? a. defibrillation b. airway management c. epinephrine d. amiodarone administration

a

a nurse is admitted 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. a room with air exhaust directly to the outdoor environment b. a room with another nonsurgical client c. a room in the ICU d. a room that is within view of the nurses station

a

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? a. propranolol b. theophylline c. Montelukast d. prednisone

a

a nurse is assessing a client who has Graves' disease. the nurse should expect which of the following laboratory results? a. decreased thyroid-stimulating hormone (TSH) level b. decreased triiodothyronine (T3) level c. decreased thyroxine (T4) level d. decreased thyroid-stimulating immunoglobins (TSI) percentage

a

a nurse is assessing a client who has asthma. which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis? a. oral mucosa b. conjunctivae c. ear lobes d. soles of the feet

a

a nurse is assessing a client who has diabetes insipidus. which of the following findings should the nurse expect? a. dehydration b. polyphagia c. hyperglycemia d. bradycardia

a

a nurse is assessing a client who has pulmonary tuberculosis. which of the following findings should the nurse expect? a. lethargy b. high-grade fever c. weight gain d. dry cough

a

a nurse is caring for a client who had a total thyroidectomy and a serum calcium level of 7.6 mg/dL. which fo the following findings should the nurse expect? a. tingling of extremities b. hypoactive deep tendon reflexes c. shortened QT intervals d. constipation

a

a nurse is caring for a client who has congestive heart failure and is taking digoxin daily. the client refused breakfast and is complaining of nausea and weakness. which of the following actions should the nurse take? a. check client's vitals b. request dietitian consult c. suggest client rests before eating the meal d. request an order for an antiemetic

a

a nurse is caring for a client who has tuberculosis and new prescriptions for rifampin and pyrazinamide. which of the following laboratory tests should the nurse instruct the client will be required while on this medication regimen? a. liver function tests b. gallbladder studies c. thyroid function studies d. blood glucose levels

a

a nurse is caring for a client with type 1 diabetes mellitus who reports feeling shaky and having palpitations. when the nurse finds the client's blood glucose to be 48mg/dL on the glucometer, he should give the client which of the following? a. graham crackers b. 1 tsp sugar c. 4 oz diet soda d. 4 oz skim milk

a

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? a. airway patency b. temperature c. urination d. pain control

a

a nurse is teaching a client who has COPD about ways to facilitate eating. which of the following statements indicates a need for further teaching? a. I will rest for at least 30 minutes before eating b. I will take my bronchodilators after meals c. I will eat five or six meals each day d. I will choose foods that are not gas forming

a

a nurse is teaching a client who has asthma about how to use an albuterol inhaler. which of the following actions by the client indicates an understanding of the teaching? a. the client holds his breath for 10 seconds after inhaling the medication b. the client takes a quick inhalation while releasing the medication from the inhaler c. the client exhales as the medication is released from the inhaler d. the client waits 10 minutes between inhalations

a

a nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back, and shoulder, shortness of breath and nausea. which of the following actions should the nurse take? a. obtain an EKG b. administer enteric coated acetaminophen c. administer ibuprofen d. maintain oxygen saturation greater than or equal to 92%

a

the nurse is caring for a client who has heart failure and a history of asthma. the nurse reviews the provider's orders and recognizes that clarification is needed for which of the following medications? a. carvedilol b. fluticasone c. captopril d. isosorbide dinitrate

a

when performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of feeling of heaviness. which of the following nursing diagnoses should the nurse identify as being the priority in the client's care? a. impaired tissue infusion b. alteration in body image c. alteration in activity tolerance d. impaired skin integrity

a

a nurse is providing teaching to a client who has stable angina and a new prescription for transdermal nitroglycerin. which of the following instructions should the nurse include? (select all that apply) a. apply the patch to a hairless area and rotate sites b. apply a new patch each morning c. remove the patch for 10-12 hours daily d. apply the patch to dry skin and cover the area with plastic wrap e. apply a new patch at the onset of anginal pain

a, b, c

a client is teaching a client who has tuberculosis and is to start combination drug therapy. which of the following medications should he nurse plan to administer? a. rifampin b. isoniazid c. acyclovir d. pyrazinamide e. montelukast

a, b, d

a nurse in a provider's office is assessing a client. the nurse should identify that which of the following findings are manifestations of pulmonary tuberculosis (select all that apply) a. night sweats b. low-grade fever c. weight gain d. flushed cheeks e. blood in the sputum

a, b, e

a nurse is caring for a client who has emphysema. which of the following findings should the nurse expect to assess in this client? (select all that apply) a. dyspnea b. bradycardia c. barrel chest d. clubbing of the fingers e. deep respirations

a, c, d

a client is teaching a client who has a new prescription for hydrochlorothiazide for management of hypertension. which of the following instructions should the nurse include? a. take this medication before bedtime b. monitor for leg cramps c. avoid grapefruit juice d,. reduce intake of potassium-rich foods

b

a home health nurse visits a client who has COPD and receives oxygen at 2L/min via nasal cannula. the client reports difficulty breathing. which of the following actions is the nursing priority? a. increase the oxygen flow to 3L/min b. assess the client's respiratory status c. call emergency services for the client d. have the client cough and expectorate secretions

b

a nurse on a medical surgical unit is performing an admission assessment of a client who has COPD with emphysema. the client reports that he has a frequent productive cough and is short of breath. the nurse should anticipate which of the following assessment findings for this client? a. respiratory alkalosis b. increased anteroposterior diameter of the chest c. oxygen saturation level 96% d. petechiae on chest

b

a nurse on a surgical unit is caring for a group of clients. which of the following is the priority action of the nurse? a. taking a telephone prescription who is being transferred from PACU b. assessing a client who experiences unilateral calf pain when ambulating c. reinforcing a client's dressing for the surgical site of an above the knee amputation d. reassuring the partner of a client who sustained a closed head injury

b

a nurse is caring for a client who asks how albuterol helps his breathing. which of the following responses should the nurse make? (Select all that apply) a. the medication will stimulate the flow of mucus b. the medication will prevent wheezing c. the medication will open the airways d. the medication will reduce inflammation e. the medication will decrease coughing episodes

b, c, e

a nurse in a provider's office is assessing a client who reports dyspnea and fatigue. physical assessment reveals tachycardia and weak peripheral pulses. the nurse should recognize these findings as manifestations of which following condition? a. asthma b. aortic valve regurgitation c. heart failure d. aortic stenosis

c

a nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction. which of the following prescriptions should the nurse take first? a. attach leads for 12 lead ECG b. obtain blood sample c. initiate oxygen therapy d. insert IV catheter

c

a nurse is caring for a client who has uncontrolled type 1 diabetes mellitus. which of the following findings should the nurse expect? a. hypertension b. hematuria c. weight loss d. bradycardia

c

a nurse is caring for a client who is taking Montelukast. which of the following outcomes indicates a therapeutic effect of the medication? a. the client experiences less muscle pain b. the client's seizure threshold is reduced c. the client experiences an increased ease of breathing d. the client's platelet count is increased

c

a nurse is giving a presentation at a community center about chronic bronchitis. which of the following information should the nurse include as effective for preventing this disorder? a. maintenance of ideal weight b. annual influenza immunization c. smoking cessation d. regular moderate exercise

c

a nurse is providing discharge teaching to a client who has asthma and a new prescription for fluticasone/salmeterol. for which of the following adverse effects should the nurse instruct the client to report to the provider? a. sedation b. increased appetite c. white coating in the mouth d. dry oral mucus membranes

c

a nurse is providing teaching to a client who has emphysema and a new prescription for theophylline. which of the following instructions should the nurse provide? a. consume a high-protein diet b. administer the medication with food c. avoid caffeine while taking this medication d. increase fluids to 1L per day

c

a nurse is reviewing the medication list for a client who has a new prescription for warfarin. the nurse should recognize that which of the following medications is incompatible with warfarin? a. furosemide b. alprazolam c. vitamin K d. Vitamin A

c

a nurse is teaching a client who has emphysema about self-management strategies. which of the following statements by the client indicates an understanding of the teaching? a. I will inhale slowly through pursed lips to help me breath better b. I will avoid getting a flu shot c. I will follow a daily diet high in calories and proteins d. I will lie on my stomach and practice abdominal breathing every day

c

a nurse is teaching a middle aged client about hypertension. which of the following information should the nurse include in the teaching? a. reaching your goal blood pressure will occur within 2 months b. diuretics are the first type of medication to control hypertension c. limit your alcohol consumption to three drinks a day d. plan to lower saturated fats to 10 percent of your daily caloric intake

c

a nurse in an emergency department is caring for a client who has diabetic ketoacidosis (DKA) and a blood glucose of 925mg/dL. the nurse should anticipate which of the following prescriptions from the provider? a. glucocorticoid medications b. dextrose 5% in 0.45 sodium chloride c. oral hypoglycemic medications d. 0.9% sodium chloride IV bolus

d

a nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. which of the following actions is the nurse's highest priority? a. initiating oxygen therapy b. providing immediate rest for the client c. positioning the client in high-Fowlers d. administering a nebulized beta-adrenergic

d

a nurse is assessing a client who has chronic respiratory insufficiency. which of the following findings should the nurse expect as result of the long-term inadequate oxygenation? a. restlessness b. retractions c. dependent edema d. clubbing of fingers

d

a nurse is assessing a client who has left-sided heart failure. which of the following findings should the nurse expect? a. jugular venous distention b. abdominal distention c. dependent edema d. hacking cough

d

a nurse is auscultating the breath sounds of a client who has asthma. when the client exhales, the nurse hears continuous high-pitched squeaking sounds. the nurse should document this as which of the following adventitious breath sounds? a. crackles b. rhonchi c. stridor d. wheezes

d

a nurse is caring for a client who has COPD. the client tells the nurse "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up". which of the following actions should the nurse take to help this client with tenacious bronchial secretions? a. maintaining semi-Fowlers position as soon as possible b. administering oxygen via nasal cannula at 2 L/min c. helping client select a low-salt diet d. encouraging client to drink 2-3 L of water daily

d

a nurse is caring for a client who has active pulmonary tuberculosis (TB) and is to be started on intravenous rifampin therapy. the nurse should instruct the client that this medication can cause which of the following adverse effects? a. constipation b. black colored stools c. staining of teeth d. body secretions turning a red-orange color

d

a nurse is caring for a client who is in myxedema coma. which of the following actions should the nurse take? a. turn the client every 4 hour b. check the client's blood pressure every 2 hours c. initiate measures to cool the client d. place the client on aspiration precautions

d

a nurse is caring for four clients who as postop from surgery 24 hours ago. at 1200 the nurse assess the clients. which of the following clients is the nurse's priority? a. a client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post meal glucose is 160 b. a client whose wound drainage at 0800 was sanguineous and now it is serosanguineous c. a client who reports pain as 4 on a scale of 1-10 at 0800 now reports pain as 6 d. a client whose blood pressure at 0800 was 138/86 and at 1200 is 106/60

d

a nurse is developing a plan of care for a client who has COPD. the nurse should include which of the following interventions in the plan? a. restrict the client's fluid intake to less than 2L a day b. provide the client with a low-protein diet c. have the client use early morning hours for exercise and activity d. instruct the client to use pursed lip breathing

d

a nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. which of the following client statements should indicate to the nurse the need for additional teaching? a. I will wear gloves when removing the food from freezer b. I will try to anticipate and avoid stressful situations when possible c. I will complete the smoking cessation program I started d. I will take my medications at the first sign of an attack

d

a nurse is planning care for a client who has a new diagnosis of diabetes insipidus. which of the following interventions should the nurse include in the plan of care? a. measure blood glucose every 4 horus b. administer diuretic c. initiate fluid restrictions d. check urine specific gravity

d

a nurse is providing discharge instructions to a client who has asthma and a new prescription for Montelukast. the nurse should instruct the client to report which of the following adverse effects to the provider? a. blurred vision b. palpitations c. constipation d. depression

d

a nurse is providing discharge instructions to a client who has asthma and is about to start taking theophylline (Theo-24). the nurse should tell the client that this medication might cause which of the following adverse effects? a. drowsiness b. constipation c. oliguria d. tachycardia

d

a nurse is providing discharge teaching to a client who has a new prescription for warfarin. which of the following statements by the client indicates an understanding of the teaching? a. "it's okay to have a couple glasses of wine with dinner each evening" b. i'll be sure to eat more foods with vitamin K c. I'll take aspirin for my headaches d. i'll use my electric razor for shaving

d

a nurse is providing instruction to a new nurse about caring for clients who are receiving diuretic therapy to treat heart failure. the nurses should explain that which of the following medications puts clients at risk for both hyperkalemia and hyponatremia? a. furosemide b. hydrochlorothiazide c. metolazone d. spironolactone

d