ATI Med-Surg Final

A nurse is reinforcing discharge teaching with a client who has AIDS. Which of the following statements should the nurse include?

"You should clean bathroom surfaces with a bleach and water solution."

A nurse is reinforcing teaching with a client who has tuberculosis (TB) and a Wprescription for isoniazid. Which of the following instructions should the nurse include?

"Your provider will monitor your liver function while you are taking this medication."

A nurse is reinforcing teaching with a client who has a new diagnosis of multiple sclerosis (MS). The client asks the nurse about the usual course of MS. Which of the following responses should the nurse make?

"Acute episodes are usually followed by remissions, which can last varying lengths of time."

A nurse is working with an assistive personnel (AP) who is assigned to bathe a client who has herpes zoster. The AP asks the nurse if herpes zoster is contagious. Which of the following responses should the nurse make?

"Herpes zoster is contagious to people who have never had chickenpox."

A community health nurse is reinforcing teaching about melanoma with a group of clients. Which of the following characteristics of lesions associated with melanoma should the nurse include in the teaching?

An irregular border

A nurse is caring for a male client who is undergoing screening tests for atherosclerosis. Which of the following laboratory findings should the nurse identify as an increased risk for this disorder?

Elevated LDL levels

A nurse is assisting with the care of a client who has a chest tube in place following a thoracotomy. Which of the following actions should the nurse take?

Elin 司 Place the drainage unit below the client's chest level.

A nurse is reinforcing teaching with a client about preventing the transmission of hepatitis A. The nurse should identify that hepatitis A is transmitted by which of the following routes?

Fecal-oral contamination

A nurse is reinforcing discharge teaching with a client who has a new permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching?

"I should check my heart rate each day."

A nurse is reinforcing discharge teaching with a client who has a new diagnosis of systemic lupus erythematosus (SLE). Which of the following statements by the client indicates an understanding of the teaching?

"I should take ibuprofen for my joint pain."

A nurse is reinforcing teaching with a client who has stomatitis due to chemotherapy. Which of the following statements by the client indicates a need for further instructions?

"I will cleanse my mouth after meals with an alcohol-based mouthwash."

A nurse is reinforcing discharge teaching with a client who has infective endocarditis about how to prevent recurrence. Which of the following statements by the client indicates an understanding of the teaching?

"I will notify my doctor before have dental procedures."

A nurse is reinforcing teaching with a client who is scheduled for a sigmoid colon resection with colostomy. Which of the following statements by the client indicates a need for further teaching?

"My diet will have to change to a soft diet after surgery."

A nurse is obtaining a weekly weight for a client who has obesity and osteoarthritis and is on a weight management program. The nurse determines that the client gained 1.36 kg (3 lb) in the past week. Which of the following statements should the nurse make?

"Were there any issues last week that kept you from focusing on your diet?"

A nurse is preparing to care for a group of clients after receiving change-of- shift report. From which of the following clients should the nurse collect data first?

A client who has emphysema and reports dyspnea

A nurse is reinforcing teaching with a client about how to perform a breast self exam (BSE). The nurse should identify which of the following findings as an indication of breast cancer?

A nontender, hard lump that is palpated in one breast

A nurse is contributing to the plan of care for a client during a sickle cell crisis. Which of the following interventions should the nurse recommend?

Administer oxygen via nasal cannula.

A nurse is preparing to administer timolol eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take?

Apply pressure to the bridge of the nose after instillation of the medication.

A nurse is collecting data from a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first?

Ask the client to identify the specific food allergies.

A nurse is reinforcing dietary teaching with a client who has diabetes mellitus. Which of the following actions should the nurse take first?

Ask the client to identify the types of foods she prefers.

A nurse is contributing to the plan of care for a client who is 72 hr postoperative following an above-the-knee amputation. Which of the following actions should the nurse recommend?

Assist the client to a prone position every 4 hr.

A nurse is caring for a client who is to have his chest tube removed. Which of the following actions should the nurse take?

Auscultate the lungs after removal.

A nurse is contributing to the plan of care for a client who has thrombocytopenia due to chemotherapy. Which of the following interventions should the nurse include?

Avoid IM injections.

A nurse is collecting data from a client who develops a fruity breath odor, dry mouth, and extreme thirst. Which of the following additional data should the nurse collect?

Blood glucose using a glucometer

A nurse is assisting with the care of a client who is to receive a transfusion of packed red blood cells (RBCS). Which of the following actions should the nurse take? (Select all that apply.)

Check and document the client's vital signs. Verify that the blood type and Rh of the packed RBCS are checked by two nurses. Provide the RN with IV tubing that has a filter.

A nurse is caring for a client who has a stage III pressure ulcer on his heel. I When preparing to irrigate the wound, which of the following actions should the nurse take first?

Check the client's pain level.

A nurse is collecting data from a client who has a fractured left femur and is in skeletal traction. Which of the following findings should the nurse identify as an indication of fat emboli to report to the provider?

Chest petechiae

A nurse is reinforcing teaching about a low-cholesterol diet with a client who had a myocardial infarction. Which of the following meal selections by the client indicates an understanding of the teaching?

Chicken breast and corn on the cob

A nurse in an urgent care clinic is collecting data from a client who sustained a fall. Which of the following findings should the nurse identify as an indication of a skull fracture?

Clear fluid coming from the nares

A nurse is caring for a client who has type 1 diabetes mellitus and a capillary blood glucose reading of 48 mg/dL. Which of the following findings should the nurse expect?

Diaphoresis

A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. Which of the following personal protective equipment (PPE) should the nurse don prior to providing client care? (Select all that apply.)

Gown Gloves

A nurse in a provider's office is caring for a client who has blepharitis. Which of the following actions should the nurse take first? W

Inspect the eyes for drainage or redness.

A nurse is monitoring a client following a thyroidectomy. Which of the following findings should the nurse identify as an indication of hypoparathyroidism?

Involuntary muscle spasms

A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first?

Lower the client to the floor.

A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following actions should the nurse take?

Monitor the client's blood glucose level.

A nurse is reinforcing discharge teaching about improving gas exchange with a client who has emphysema. which of the following information should the nurse include in the teaching?

O use pursed-ip breathing during periods of dyspnea.

A nurse is contributing to the plan of care for a client who had a stroke. The client has hemiplegia and occasional urinary incontinence. Which of the following interventions should the nurse recommend?

Offer the client a bedpan every 2 hr.

A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which of the following actions should the nurse take?

Pinch the soft portion of the client's nose for 10 min.

A nurse is contributing to the plan of care for a client who has thrombophlebitis. Which of the following actions should the nurse recommend for the plan of care?

Place compression stockings on the lower extremities.

A nurse is contributing to the plan of care for a client who has cancer and is scheduled to receive internal radiation therapy. Which of the following actions should the nurse recommend?

Place the client in a private room.

A home health nurse enters a client's home and finds a used insulin syringe, without a cap, on the table. Which of the following actions should the nurse take?

Place the syringe in a puncture-proof disposal container.

A nurse is caring for a client following a hip arthroplasty. The nurse should place an abduction pillow on the client for which of the following purposes?

Preventing dislocation of the hip during position changes or movement

A nurse is reinforcing teaching with a client who has tuberculosis and a prescription for rifampin. The nurse should identify which of the following findings as a harmless and expected adverse effect of rifampin?

Red-orange discoloration of urine

A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following actions should the nurse take?

Report viscous drainage with clots to the provider.

A nurse is reviewing a client's laboratory report. The client's ABG levels are pH 7.5, Paco2 32 mm HG, and HCO3- 24 mEg/L. The nurse should determine that the client has which of the following acid-base imbalances?

Respiratory alkalosis

A nurse in an urgent care clinic is collecting data from a client who has extensive burns, including on her face. Which of the following data should the nurse collect first?

Respiratory rate

A nurse is collecting data from a client who has encephalitis due to West Nile virus. Which of the following findings should the nurse expect? (Select all that apply.)

Stiff neck Photophobia Lethargy

A nurse is reinforcing teaching with a client who has gout and urolithiasis. The client asks how to prevent future uric acid stones. Which of the following suggestions should the nurse make? (Select all that apply.)

Take allopurinol as prescribed. Exercise several times a week. Limit intake of foods high in purine.

A nurse is reinforcing teaching with a client who has a history of tonic-clonic seizures and is scheduled for a standard electroencephalogram (EEG). Which of the following instructions should the nurse include in the teaching?

Thoroughly shampoo hair prior to the EEG.

A nurse is caring for a client who is scheduled to receive intermittent peritoneal dialysis. Which of the following actions should the nurse take?

Weigh the client before and after each dialysis treatment.