ATI Med-Surg Ch. 1-25
A nurse in a provider's office is obtaining a nursing history from a client who has cluster headaches. Which of the following are expected findings?
Client is experiencing altered sleep-wake cycle. Headache occurs at approximately the same time of the day. Nasal congestion and drainage occur
A nurse in a clinic is caring for a client who has sinusitis. Which of the following techniques should the nurse use to identify clinical manifestations of this disorder?
Palpation of the orbital areas
A nurse is reinforcing teaching with a client who has Parkinson's disease and has received a prescription for bromocriptine. Which of the following instructions should the nurse include in the teaching?
Rise slowly when standing
A nurse is planning care for a client who is receiving mechanical ventilation. Which mode of ventilation increases the effort of the client's respiratory muscles?
Synchronized intermittent mandatory ventilation Continuous positive airway pressure Pressure support ventilation
A nurse is providing reaching to the partner of an older adult client who has Alzheimer's disease and has a new prescription for donepezil. Which of the following statements by the partner indicates the teaching is effective?
"This medication should help my husband's daily function."
A nurse is providing education to a client who is to undergo an electroencephalogram (EEG) the next day. Which of the following information should the nurse include in the teaching?
"Try to stay awake most of the night prior to the procedure."
A nurse is caring for an older adult client who has a new diagnosis of type 2 diabetes mellitus and reports difficulty following the diet and remembering to take the prescribed medication. Which of the following are appropriate actions by the nurse?
Ask the dietitian to assist with meal planning Contact the client's support system Encourage the use of a daily medication dispenser. Provide educational materials for home use
A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following should the nurse include in the teaching?
Assess breath sounds every 1 to 2 hours
A nurse working on a medical-surgical unit admits a client. Two hours after admission, the client's SaO2 is 91% and he is exhibiting audible wheezes and use of his accessory muscles. Which of the following medications should the nurse expect to administer?
Beta2 agonist
Which of the following clients have an increased risk for developing pneumonia?
Client who has dysphagia Client who has AIDS Client who has a closed head injury and is receiving ventilation Client who has myasthenia gravia
A nurse on a medical-surgical unit is caring for a group of clients. The nurse should notify the rapid response team for which of the following clients?
Client who reports right calf pain and shortness of breath
A nurse is planning care for a client who has dysphagia and has a new dietary prescription. Which of the following should the nurse include in the plan of care?
Have suction equipment available for use Use thickened liquids Place food on the client's unaffected side of her mouth Teach the client to swallow with her neck flexed
A nurse is reviewing the health record of a client who has a malignant brain tumor and notes the client has a positive Romberg sign. Which of the following actions should the nurse take to assess for this sign?
Have the client stand erect with eyes closed.
A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP?
Headache Dilated Pupils Decorticate posturing
A nurse is assessing a client who reports severe headache and a stiff neck. The nurse/s assessment reveals positive Kernig's and Brudzinski's signs. Which of the following actions should the nurse perform first?
Implement droplet isolation precautions
A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse instruct the client to do?
Perform the Valsalva maneuver
A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take?
Position the client in an upright position, leaning over the bedside table
A nurse is planning care for a client who suffered a spinal cord injury (SCI) involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. Which of the following should be the nurse's highest priority?
Prevention of further damage to the spinal cord
A nurse is caring for a client who displays signs of stage 3 Parkinson's disease. Which of the following actions should the nurse include in the plan of care?
Provide a walker for ambulation
A nurse is planning care for a client who has bacterial meningitis. Which of the following actions should the nurse include in the plan of care?
Provide an emesis basin at the bedside Administer antipyretic medication as prescribed Perform a skin assessment
A nurse is assessing a client who has a seizure disorder. The client reports he thinks he is about to have a seizure. Which of the following actions should the nurse implement?
Provide privacy Ease the client to the floor if standing Move furniture away from the client Loosen the client's clothing Protect the client's head with padding
A nurse is developing a plan of care for the nutritional needs of a client who has stage 4 Parkinson's disease. Which actions should the nurse include in the plan of care?
Record diet and fluid intake daily Add thickener to liquids Offer nutritional supplements between meals
A nurse in a clinic is caring for a client who has been experiencing mild to moderate vertigo due to benign paroxysmal vertigo for several weeks. Which of the following actions should the nurse recommend to help control the vertigo?
Reduce exposure to bright lighting Move head slowly when changing positions Plan evenly spaced daily fluid intake
A nurse in a clinic is caring for a client who has frequent migraine headaches. The client asks about foods that may cause headaches. The nurse should recommend that the client avoid which of the following foods?
Salted cashews
A nurse is caring for a client who has global aphasia (both receptive and expressive). Which of the following should the nurse include in the client's plan of care?
Speak to the client at a slower rate Look directly at the client when speaking Allow extra time for the client to answer Give instructions one step at a time
A nurse is providing discharge teaching to a client who has COPD and has a new prescription for albuterol. Which of the following statements made by the client indicates an understanding of the teaching?
"I can have an increase in my heart rate while taking this medication."
A nurse in a clinic is teaching a client who has a history of migraine headaches about a new prescription for zolmitriptan. Which of the following statements by the client indicates understanding of the teaching?
"I should take this medication as soon as I notice symptoms developing."
A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse?
"I take antacids several times a day."
A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. Which of the following statements by the client indicates the teaching was effective?
"I take this medication to prevent asthma attacks."
A nurse is developing a plan of care for a client who is scheduled for a cerebral angiogram with contrast dye. Which of the following statements by the client should the nurse report to the provider?
"I think I may be pregnant." "I take Coumadin." "I am allergic to shrimp."
A nurse is instructing a client on the use of an incentive spirometer. Which of the following statements made by the client indicates an understanding of the teaching?
"I will take in a deep breath and hold it before exhaling."
A nurse is completeing discharge teaching with a client who has a new prescription for prednisone for asthma. Which of the following client statements indicates a need for further teaching?
"I will take my medication on an empty stomach."
A home health nurse is teaching a client who has active tuberculosis. The provider has prescribed the following medication regimen: isoniazid 250 mg PO daily. rifampin 500 mg PO daily, pyrazinamide 750 mg PO daily, and ethambutol 1 mg PO daily. Which of the following client statements indicate understanding of the teaching?
"I will wash my hands each time I cough." "I will wear a mask when I am in a public area."
A nurse is reviewing discharge instructions for a client who experienced a pneumothorax. Which of the following should be included in the teaching?
"Notify your provider if you experience a cough."
A nurse is discharging a client who has COPD. Upon discharge, the client is concerned that he will never be able to leave his house now that he is on continuous oxygen. Which of the following is an appropriate response by the nurse?
"There are portable oxygen delivery systems that you can take with you."
A nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed on a multimedication regimen. Which of the following instructions should the nurse give the client related to the medication ethambutol?
"Watch for any changes in vision."
A nurse is preparing to administer a new prescription for isoniazid to a client who has tuberculosis. Which of the following is an appropriate statement by the nurse about this medication?
"You may notice tingling of your hands."
A nurse is caring for a client following a trabeculectomy. Which of the following statements should the nurse include in the teaching?
"You need to limit your housekeeping activities."
A nurse is teaching a client who has tuberculosis. Which of the following statements should the nurse include in the teaching?
"You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication."
A nurse is preparing to administer morphine 2.5 mg IV bolus to a client who has a pneumothorax. Available is morphine injection 10mg/mL. How many mL should the nurse administer?
0.3 mL
A nurse is caring for a client who has pneumonia. Assessment findings include temperature 37.8C (100F), respirations 30/min, BP 130/76, heart rate 100/min, and SaO2 91% on room air. Using a scale of 1 to 4, with 1 being the highest priority, prioritize the following nursing interventions.
1) administer oxygen therapy 2) perform a sputum culture 3) administer antibiotics as prescribed 4) administer an antipyretic medication to promote client comfort
A nurse is caring for several clients. Which of the following clients are at risk for having a pulmonary embolism?
A client who has a BMI of 30 A client who has a fractured femur A client who has chronic atrial fibrillation
A nurse is evaluating clients at a health fair for modifiable variables affecting health and wellness. The nurse identifies which of the following as a modifiable variable?
A male who smokes on social occasions A female with a BMI of 28 An infant with reflux
A nurse is reviewing the common emergency management protocol for clients during a cardiac emergency. Which of the following is an appropriate action by the nurse?
Administer IV epinephrine.
A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states that she is anxious because she feels that she cannot get enough air. Vital signs are: heart rate 117/min., respiratory rate 38/min., temperature 38.4C (101.2F), and blood pressure 100/54 mm Hg. Which of the following actions is the priority action at this time?
Administer oxygen therapy
A nurse is reviewing discharge instructions with a client who has a new diagnosis of migraine headaches. Which of the following instructions should the nurse include?
Apply a cool cloth to the face during a headache.
A nurse is caring for a client who has myasthenia gravis (MG) and has developed drooping eyelids. Which of the following actions should the nurse take?
Apply lubricating eye drops Tape eyes closed at night
A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the client's chest tube has become disconnected. Which of the following actions should the nurse take first?
Apply sterile gauze to the insertion site.
A nurse is beginning a physical assessment of a client who was recently diagnosed with multiple sclerosis (MS). Which of the following findings should the nurse expect?
Areas of paresthesia Involuntary eye movements Ataxia
A nurse is caring for a client post-lumbar puncture who reports a throbbing headache when sitting upright for meals. Which of the following are appropriate actions by the nurse?
Assist client to eat meals while lying flat in bed. Administer an opioid medication Encourage client to increase fluid intake
A nurse working in a long-term care facility is planning care for a client in stage 5 of Alzheimer's disease. Which of the following interventions should be included in the plan of care?
Assist with ADLs
A nurse is caring for a client who has Parkinson's disease and displays signs of bradykinesia. Which of the following is an appropriate action by the nurse?
Assist with hygiene as needed
A nurse is performing an otoscopic examination of a client. Which of the following is an unexpected finding?
Black cerumen partially occluding the TM
A nurse is caring for a client who has a new diagnosis of cataracts. Which of the following clinical manifestations should the nurse expect to find?
Blurred vision White pupils
A nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. Which of the following effects should the nurse anticipate?
Bradypnea Orthostatic hypotension Nausea
A nurse is assessing a client following a bronchoscopy. Which of the following findings should the nurse report to the provider?
Bronchospasms
A nurse is caring for a client who experienced a cervical spine injury 3 months ago. Which of the following types of bladder management methods should the nurse use for this client?
Condom catheter
A nurse in the emergency department is assessing a client with suspected flail chest. Which of the following clinical findings confirm this diagnosis?
Cyanosis Hypotension Dyspnea Paradoxic chest movement
A nurse is completing an assessment of a client who has increased intracranial pressure. Which of the following are expected findings?
Disoriented to time and place Restlessness and irritability Unequal pupils Headache
A nurse is assessing a client who has experienced a gunshot wound. Findings include blood pressure 108/55 mm Hg, hear rate 124/min, respiratory rate 36/min, temperature 38.6C (101.4F), and SaO2 95% on oxygen 15L/min via nonrebreather mask. The client reports dyspnea and pain. The nurse assesses the client 30 min. later. Which of the followingg should the nurse report to the provider?
Distended neck vein Tracheal deviation Heart rate 154/min
A nurse is caring for a client following a thoracentesis. Which of the following clinical manifestations should the nurse recognize as risks for complications?
Dyspnea Fever Hypotension
A nurse is assessing a client for changes in the level of consciousness using the Glasgow Coma Scale. The client opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of the following is the correct scoring by the nurse using the Scale that indicates the client has a moderate head injury?
E3+ V4+ M4= 11
A nurse is reviewing the health record of a client who has a middle ear disorder. Which of the following are expected findings?
Enlarged adenoids Report of recent colds Report of frequent ingestion of ibuprofen
A nurse is assessing a client with asthma. Which of the following is a risk factor associated with this disease?
Environmental allergies
A nurse is caring for a client who has Alzheimer's disease. A family member of the client asks the nurse about risk factors for the disease. Which of the following should be included in the nurse's response?
Exposure to metal waste products Previous head injury History of herpes infection
A nurse is caring for a male older adult client who has a new diagnosis of glaucoma. Which of the following should the nurse recognize as risk factors associated with this disease?
Genetic predisposition Hypertension Age Diabetes Mellitus
A nurse in the emergency department is assessing a client who is unresponsive. The client's partner states, "He was pulling weeds in the yard and dropped to the ground." Which of the following techniques should the nurse use to open the client's airway?
Head-tilt, chin-lift
A nurse is caring for a client who is to receive fibrinolytic thrombotic therapy. Which of the following should the nurse recognize as a contraindication to the therapy?
Hip arthroplasty 2 weeks ago
A nurse is caring for a client who has experienced a right-hemisphere stroke. Which of the following are expected findings?
Impulse control difficulty Left hemiplegia Loss of depth perception Lack of awareness
A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding?
Inability to recognize familiar objects
A nurse is caring for a client admitted to the hospital with respiratory difficulty after being diagnosed with amyotrophic lateral sclerosis (ALS) approximately 1 year ago. Which of the following client findings should the nurse anticipate?
Incontinence Ineffective cough
A nurse is caring for a client who is having surgery for the removal of an encapsulated acoustic tumor. Which of the following potential complications should the nurse monitor for postoperatively?
Increased intracranial pressure Hydrocephalus Seizures
A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (Ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy?
Infection
A nurse is caring for a client who has ingested a toxic agent. Which of the following actions should the nurse plan to take?
Instill activated charcoal. Perform a gastric lavage with aspiration. Complete a whole-bowel irrigation.
A nurse is obtaining a health history from a client who is being evaluated for the cause of frequent headaches. Which of the following questions should the nurse ask to identify the clinical findings of migraine headaches?
Is there a pattern of headaches among family members?
A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform first?
Keep the client in a side-lying position.
A nurse is preparing to administer a new prescription prednisone to a client who has COPD. Which of the following should the nurse monitor for?
Monitor the client for hypokalemia Observe the client for fluid retention Advise the client to report black, tarry stools.
A nurse is caring for a client who has just undergone a craniotomy for a supratentorial tumor. Which of the following postoperative prescriptions should the nurse clarify with the provider?
Morphine sulfate 2 mg IV bolus PRN every 2 hr for pain
A nurse is caring for a client who experienced a cervical spin injury 24 hr ago. Which of the following types of prescribed medications should the nurse clarify with the provider?
Muscle relaxants
A nurse is assessing a client who is in respiratory distress. The nurse should recognize that which of the following can cause a low pulse oximetry reading?
Nail polish Inadequate peripheral circulation Edema
A nurse is reviewing the prescriptions for a client who has a pneumothorax. Which of the following actions should the nurse perform first?
Obtain a large-bore IV needle for decompression.
A nurse is providing information to a group of clients at a local community center about tuberculosis. Which of the following clinical manifestations should be included in the teaching?
Persistent cough Fatigue Night sweats Purulent sputum
A nurse is assessing a client for manifestation of Parkinson's disease. Which of the following are expected findings?
Pill-rolling tremor of the fingers Shuffling gait Drooling Lack of facial expressions
A nurse is completing discharge teaching to a client who has seizures and received a vagal nerve stimulator to decrease seizure activity. Which of the following information should the nurse include in the teaching?
Place a magnet over the implantable device when an aura occurs.
A nurse is assessing for the presence of Brudzinski's sign in a client who has suspected meningitis. Which of the following are appropriate actions by the nurse when performing this technique?
Place client in supine position Place hands behind the client's neck Bend client's head toward chest
A nurse is caring for a client who has AD and falls frequently. Which of the following actions should the nurse take first to keep the client safe?
Place the client in a room close to the nurses' station.
A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention?
Place the client's bedside table on the right side of the bed.
A nurse is assessing a client who has a pulmonary embolism. Which of the clinical manifestations should the nurse expect to find?
Pleural friction rub Petechiae Tachycardia
A nurse is assessing the pain level of a client who has come to the emergency department reporting severe abdominal pain. The nurse asks the client whether he has nausea and has been vomiting. The nurse is assessing which of the following?
Presence of associated symptoms
A nurse is caring for a client who has a C4 spinal cord injury. Which of the following should the nurse recognize the client as being at the greatest risk for?
Respiratory compromise
A nurse is caring for a client with a spinal cord injury who reports a severe headache and is sweating profusely. Vital signs include BP of 220/110 mm Hg, with an apical heart rate of 54/ min. Which of the following actions should the nurse take first?
Sit the client upright in bed
A nurse is planning to instruct a client on how to perform pursed-lip breathing. Which of the following should the nurse include in the plan of care?
Take a deep breath in through your nose.
A nurse is providing discharge instructions to a female client who has a prescription for phenytoin. Which of the following information should the nurse include?
Take the medication at the same time every day.
A nurse is caring for a client who has suspected Meniere's disease. Which of the following is an expected finding?
Unilateral hearing loss
A nurse is caring for a client who has dyspnea and is to receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client?
Venturi mask
A nurse in the emergency department is caring for a client who was admitted with an acute asthma attack. Which of the following indicates the client's respiratory status is declining?
Wheezing Retraction of sternal muscles Premature ventricular complexes (PVCs)
A nurse is assessing a client who is reporting pain despite analgesia. The nurse can best assess the intensity of the client's pain by
offering the client a pain scale to measure his pain.
A nurse is obtaining a history for a client who has pain. The nurse's guiding principle throughout this process should be that
pain is whatever the client says it is
A nurse is teaching a client who has ALS about a new prescription for riluzole. Which of the following instructions should the nurse give the client?
"Avoid consuming alcoholic beverages."
A nurse is teaching a group of clients about influenza. Which of the following statements by a client requires clarification?
"I need to avoid drinking fluids if I develop symptoms."
A nurse is reviewing the health record of a student newly admitted to a university and living in a dormitory. The health record indicates the student requires follow-up immunizations. Which of the following organisms should the nurse plan to vaccinate the student against?
Neisseria meningitidis
A nurse is caring for a client hwo has a closed-head injury with ICP readings range from 16 to 22 mm Hg. Which of the following action should the nurse take to decrease the potential for raising the client's ICP?
Not suctioning the endotracheal tube. Hyperventilate the client Administer a stool softener
A nurse is caring for a client who was just told she has breast cancer and the nurse evaluates the client's response. Which of the following statements by the client reflects a lack of understanding of an illness perspective?
"I need a second opinion; there is no lump."
A nurse is completing discharge teaching to a client following a stapedectomy. Which of the following statements by the client indicates understanding of the teaching?
"I will cover my ear when washing my hair."
A nurse instructs a client who has MG about home care and the risk factors that can exacerbate the disease. Which of the following client statements indicates a nee for further teaching?
"I will soak in a warm bath every day."
A nurse is reviewing a prescription for dexamethasone with a client who has an expanding brain tumor. Which of the following are appropriate statements by the nurse?
"It is given to reduce swelling of the brain." "You may notice weight gain." "It can cause you to retain fluids."
A nurse is caring for a client who has a benign brain tumor. The client asks the nurse if he can expect this same type of tumor to occur in other areas of his body. Which of the following is an appropriate response by the nurse?
"It is limited to brain tissue."
A nurse is orienting a newly licensed nurse who is caring for a client that is receiving mechanical ventilation, which has been placed on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse demonstrates an understanding of PSV?
"It permits spontaneous ventilation to decrease the work of breathing."
A nurse is planning care for a client who has meningitis and is at risk for increased intracranial pressure (ICP). Which of the following are appropriate nursing actions?
Implement seizure precautions Turn off room lights and television Monitor for impaired extraocular movements
A nurse in a health care clinic is evaluating the level of wellness for clients using the health/wellness/illness continuum tool. Which of the following clients is measured at the center of the continuum?
A young male who has a long history of well-controlled rheumatoid arthritis
A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care?
Encourage the client to cough ever 2 hr. Check for continuous bubbling in the suction chamber.
A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings?
Gentle constant bubbling in the suction control chamber Rise and fall in the level of water in the water seal chamber with inspiration and expiration
A nurse is caring for a client who was recently admitted to the emergency department following a head-on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/ min, and a laceration on his forehead that is bleeding. Which of the following is the priority nursing action at this time?
Keep neck stabilized
A nurse is assessing a client following cataract surgery. The client reports nausea and severe eye pain. Which of the following actions should the nurse take?
Notify the provider
A nurse in a clinic is caring for a client who was brought to the clinic by her partner. The partner states the client woke up this morning, did not recognize him, and did not know where she was. The client reports chills and chest pain that is worse upon inspiration. Which of the following is the priority nursing action?
Obtain baseline vital signs and oxygen saturation
A nurse is caring for an older client who has diabetes mellitus. The client reports loss of peripheral vision. For which of the following is the client at risk?
Open-angle glaucoma
A nurse is reviewing trigger factors that can cause seizures with a client who has a new diagnosis of generalized seizures. Which of the following information should the nurse include in this review?
Overwhelming fatigue should be avoided Caffeinated products should be removed from the diet. Looking at flashing lights should be limited
A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the client's room?
Oxygen Sterile Water Enclosed hemostat clamps Occlusive dressing
A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure is in the client's room?
Oxygen equipment Pulse oximeter Sterile dressing
A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which for the following is the priority assessment?
Oxygen saturation
A nurse is caring for a client who is experiencing respiratory distress. Which of the following are early clinical manifestations of hypoxemia?
Pale skin Elevated blood pressure
A nurse is making a home visit to a client who has AD. The client's partner states that the client is often disoriented to time and place, is unsteady on his feet, and has a history of wandering. Which of the following safety measure should the nurse review with the partner?
Remove floor rugs Provide increased lighting in stairwells Install handrails in the bathroom Place the mattress on the floor
A nurse in the emergency department is caring for a client who fell through the ice on a pond and is unresponsive and breathing slowly. Which of the following are appropriate actions by the nurse?
Remove wet clothing. Apply warm blankets. Apply a heat lamp. Infuse warmed IV fluids.
