ATI Med Surg Proctored Exam Practice Qs

A nurse is assessing a client who has cholecystitis. Which of the following findings should the nurse expect? A. Blumberg's sign B. Ascites C. Gastrointestinal bleeding D. Kehr's sign

A. Blumberg's sign The nurse should expect to find rebound tenderness (Blumberg's sign) in a client who has cholecystitis. This response can be an indication of peritoneal inflammation. :B. The nurse should expect to find ascites in a client who has chronic pancreatitis or pancreatic cancer. C. The nurse should expect to find gastrointestinal bleeding in a client who has pancreatic cancer. D. The nurse should expect to find a positive Kehr's sign in a client who has liver trauma.

A nurse is examining the ECG of a client who has hyperkalemia. Which of the following ECG changes should the nurse expect? A. Elevated ST segments B. Absent P waves C. Depressed ST segments D. Varying PP intervals

A. Elevated ST segments Elevated ST segments can indicate hyperkalemia and pericarditis.

A nurse is monitoring a newly licensed nurse who is caring for a client. The client has active pulmonary tuberculosis, was placed on airborne precautions, and is scheduled for a chest X-ray. The nurse should instruct the newly licensed nurse to take which of the following actions? A. Have the client wear a surgical mask. B. Wear a gown for protection from the client's infection. C. Ask the radiology staff to perform a portable chest X-ray in the client's room. D. Place an N-95 respirator on the client.

A. Have the client wear a surgical mask.

A nurse is caring for a client who is NPO and has an NG tube to suction. When the client reports nausea, which of the following actions should the nurse take? A. Irrigate the tube with normal saline solution B. Provide oral hygiene C. Clamp the tube for 30 min D. Increase the amount of suction

A. Irrigate the tube with normal saline solution When a client with an NG tube develops nausea, the nurse should first attempt to irrigate the tube to determine patency. If the tube is not patent, gastric pressure cannot decrease, and the steady or increasing pressure can cause nausea. Incorrect Answers: B. Although oral hygiene is an appropriate comfort measure for a client who is NPO, it will not eliminate the client's nausea. C. Clamping the NG tube will likely worsen the client's nausea. D. Increasing the suction can either be ineffective or increase the risk of tissue injury.

A nurse is teaching a newly licensed nurse about caring for a client who is scheduled for an esophagogastric balloon tamponade tube to treat bleeding esophageal varices. Which of the following pieces of information should the nurse include in the teaching? A. The client will be placed on mechanical ventilation prior to this procedure. B. The tube will be inserted into the client's trachea. C. The client will receive a bowel preparation with cathartics prior to this procedure. D. The tube allows the application of a ligation band to the bleeding varices.

A. The client will be placed on mechanical ventilation prior to this procedure. The client will require intubation and mechanical ventilation prior to this procedure to protect the airway.

A nurse is monitoring a client for reperfusion following thrombolytic therapy to treat acute myocardial infarction (MI). Which of the following indicators should the nurse identify to confirm reperfusion? A. Ventricular dysrhythmias B. Appearance of Q waves C. Elevated ST segments D. Recurrence of chest pain

A. Ventricular dysrhythmias The appearance of ventricular dysrhythmias following thrombolytic therapy is a sign of reperfusion of the coronary artery.

A nurse is caring for a client who is postprocedural following a lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? SATA. a. Use the GCS scale to assess the client b. Assist the client into a supine position c. Administer an opioid analgesic d. Encourage the client to increase PO fluid intake e. Instruct the client to perform coughing and deep breathing

B, D

A nurse is assessing a client who has peripheral vascular disease and a venous ulcer on the right ankle. Which of the following findings should the nurse expect in the client's affected extremity? A. Absent pedal pulses B. Ankle swelling C. Hair loss D. Skin atrophy

B. Ankle swelling The nurse should identify that swelling of the ankle is a manifestation of venous insufficiency due to poor venous return. Other manifestations can include brown pigmentations and cellulitis.

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? A. Kussmaul respirations B. Diaphoresis C. Decreased skin turgor D. Ketonuria

B. Diaphoresis A client who has a blood glucose level below 70 mg/dL will exhibit manifestations of hypoglycemia. Expected findings associated with hypoglycemia include weakness, hunger, diaphoresis, nausea, shakiness, and confusion.

A nurse is preparing an in-service presentation about the management of myocardial infarction (MI). Death following MI is often a result of which of the following complications? A. Cardiogenic shock B. Dysrhythmias C. Heart failure D. Pulmonary edema

B. Dysrhythmias According to evidence-based practice, dysrhythmias (specifically ventricular fibrillation) are the most common cause of death following MI. Therefore, nurses should monitor clients' ECGs carefully for dysrhythmias and report and treat them immediately.

A nurse is assessing a client who is 12 hr postoperative following an open cholecystectomy. Which of the following findings should the nurse report to the provider? A. Hypoactive bowel sounds B. Indwelling urinary catheter output of 25 mL/hr C. Heart rate of 96/min D. Serous drainage at the surgical incision site

B. Indwelling urinary catheter output of 25 mL/hr The nurse should report a urinary output of <30 mL/hr to the provider, as this can indicate hypovolemia or renal complication.

A nurse is examining the ECG of a client who has frequent premature ventricular contractions (PVCs). Which of the following QRS changes should the nurse expect to see on the client's ECG? A. Narrower than usual QRS complexes B. Much greater amplitude than the usual QRS complexes C. Same polarity as the usual QRS complexes D. Immediate resumption of the usual rhythm

B. Much greater amplitude than the usual QRS complexes The QRS complexes unusually have greater amplitude in height and depth in clients with PVCs.

A nurse is caring for a client who is experiencing autonomic dysreflexia due to a C5 spinal cord injury. After checking the client's vital signs, which of the following actions should the nurse perform next? A. Administer nifedipine B. Place the client in a high-Fowler's position C. Check for urinary retention D. Check for a fecal impaction

B. Place the client in a high-Fowler's position According to evidence-based practice, the nurse should first place the client in a high-Fowler's position to decrease the client's blood pressure and reduce the risk of end-organ damage from the sudden rise in blood pressure.

A nurse is caring for a client who has a percutaneous endoscopic gastrostomy (PEG) tube and is receiving intermittent feedings. Prior to initiating the feeding, which of the following actions should the nurse take first? A. Flush the tube with water B. Place the client in the semi-Fowler's position C. Cleanse the skin around the tube site D. Aspirate the tube for residual contents

B. Place the client in the semi-Fowler's position The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second priority because adequate ventilatory effort is essential for oxygen exchange to occur. Circulation is the third priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them.

A nurse is caring for a semiconscious client who had a small-bore NG tube placed yesterday for the administration of enteral feeding. Which of the following methods should the nurse use to verify correct tube placement? (Select all that apply.) A. Auscultate injected air B. Verify the initial X-ray examination C. Measure the length of the exposed tube D. Determine the pH of aspirated fluid E. Check the aspirated fluid for glucose

B. Verify the initial X-ray examination C. Measure the length of the exposed tube D. Determine the pH of aspirated fluid

A nurse is teaching a client who has polycythemia vera about self-care measures. Which of the following interventions should the nurse include? A. "Drink at least 1 liter of fluid each day." B. "Continuously wear support hose." C. "Elevate your legs when sitting." D. "Use dental floss daily."

C. "Elevate your legs when sitting." Clients who have polycythemia vera should elevate their legs when seated to avoid venous pooling with subsequent clot formation.

A nurse is caring for a client who has a major burn injury and is experiencing third spacing. Which of the following fluid or electrolyte imbalances should the nurse expect? A. Hypokalemia B. Hypernatremia C. Elevated Hct D. Decreased Hgb

C. Elevated Hct The nurse should expect a client who is experiencing third spacing resulting from a major burn to have an elevated hematocrit level as blood volume is reduced by vascular dehydration. Incorrect Answers: A. The nurse should expect the client to have hyperkalemia as a result of potassium being leaked from cellular injury. B. The nurse should expect the client to have hyponatremia once sodium leaks into the interstitial space, causing decreased levels in the blood. D. The nurse should expect the client to have an increased hemoglobin level as blood volume is reduced by vascular dehydration.

A nurse is caring for a client who had a left lower lobectomy to treat lung cancer. Which of the following factors will have a significant impact on the plan of care for this client? A. The client will need intensive smoking-cessation education. B. After surgery, the prognosis for clients with lung cancer is usually good. C. Lung cancer usually has metastasized before the client presents with symptoms. D. Oxygen therapy is ineffective following a lobectomy.

C. Lung cancer usually has metastasized before the client presents with symptoms. The nurse should be aware that lung cancer is usually at an advanced stage before the client has any manifestations. This has implications for both short-term and long-term care options for the client.

A nurse is caring for a client who has diabetes insipidus. For which of the following findings should the nurse monitor? A. Proteinuria B. Oliguria C. Polyuria D. Glycosuria

C. Polyuria

A nurse is caring for a client with Clostridium difficile who has contact-isolation precautions in place. Which of the following actions should the nurse perform? A. Instruct visitors to maintain a distance of at least 1 m (3 ft) from the client. B . Wash hands with antimicrobial soap after leaving the client's room. C. Use dedicated equipment for the client. D. Keep the doors to the client's room closed at all times.

C. Use dedicated equipment for the client. The nurse should use dedicated equipment that is left in the room for a client who has contact-isolation precautions in place. Incorrect Answers: A. The nurse should instruct visitors to maintain a distance of at least 1 m (3 ft) from a client who has droplet-isolation precautions in place. B. The nurse should wash hands with antimicrobial soap before leaving the room of a client who has contact-isolation precautions in place. D. The nurse should keep the doors to the client's room closed at all times when airborne-isolation precautions are in place.

A nurse is providing teaching to 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? A. "Because most of my colon is still intact and functioning, my stool will be formed." B. "My stoma will appear large at first, but it will shrink over the next several weeks." C. "My colostomy will begin to function in 2 to 6 days after surgery." D. "I'll have to consume a soft diet after surgery."

D. "I'll have to consume a soft diet after surgery." The nurse should identify that this statement requires further teaching. After surgery, the client quickly returns to a regular diet, and there are no food restrictions unless the client chooses to decrease the intake of foods that increase gas or odor.

A nurse is teaching a client who has a new diagnosis of primary open-angle glaucoma (POAG). Which of the following pieces of information should the nurse include in the teaching? (Select all that apply.) A. Lost vision can improve with eye drops. B. Administer eye drops as needed for vision loss. C. Glasses will be necessary to correct the accompanying presbyopia. D. Driving can be dangerous due to the loss of peripheral vision. E. Laser surgery can help reestablish the flow of aqueous humor.

D. Driving can be dangerous due to the loss of peripheral vision. E. Laser surgery can help reestablish the flow of aqueous humor.

A nurse is caring for a client following a stroke. Which of the following actions should the nurse take first? A. Obtain coagulation laboratory studies from the client B. Apply pneumatic compression boots to the client C. Request a referral for a speech-language pathologist D. Keep the client NPO

D. Keep the client NPO The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to keep the client NPO due to the risk of aspiration as a result of the stroke. The client should be screened for the ability to swallow and should not receive anything by mouth until this has been completed. A client who has experienced a cerebrovascular accident is at risk for dysphagia, which increases the change of life-threating aspiration.

A nurse is assessing a client who has Kaposi's sarcoma. Which of the following findings should the nurse expect? A. Nonproductive cough, fever, and shortness of breath B. Lesions on the retina that produce blurred vision C. Onset of progressive dementia D. Reddish-purple skin lesions

D. Reddish-purple skin lesions Kaposi's sarcoma is commonly associated with AIDS and manifests as hyperpigmented multicentric lesions that can be firm, flat, raised, or nodular. Following a biopsy, the lesions are treated with radiation and/or chemotherapy.

A nurse is assessing a client who sustained superficial partial-thickness and deep partial-thickness burns 72 hr ago. Which of the following findings should the nurse report to the provider? A. Edema in the burned extremities B. Severe pain at the burn sites C. Urine output of 30 mL/hr D. Temperature of 39.1°C (102.4°F)

D. Temperature of 39.1°C (102.4°F) An elevated temperature is an indication of infection, and the nurse should report this finding to the provider. Sepsis is a critical finding following a major burn injury. Initially, burn wounds are relatively pathogen-free. On approximately the third day following the injury, early colonization of the wound surface by gram-negative organisms changes to predominantly gram-positive opportunistic organisms.

A client is being discharged home with oxygen therapy delivered through a nasal cannula. Which of the following instructions should the nurse provide to the client and family members? A. Use battery-operated equipment for personal care. B. Apply mineral oil to protect the facial skin from irritation. C. Remove the television set from the client's bedroom. D. Wear cotton clothing to avoid static electricity.

D. Wear cotton clothing to avoid static electricity. The use of cotton clothing will limit the buildup of static electricity. Oxygen is a highly combustible gas. The use of oxygen in high concentrations has great combustion potential and readily fuels fire. Although it will not spontaneously burn or cause an explosion, it can easily cause a fire in a client's room if it contacts a spark.

A nurse is caring for a client who has manifestations of acute tubular necrosis (ATN) following a kidney transplantation. Which of the following interventions should the nurse anticipate for this client? (Select all that apply.) A. Hemodialysis B. Biopsy C. Immunosuppression D. Balloon angioplasty E. Surgical repair

A, B, C Clients who develop ATN after transplantation surgery might need dialysis until they have an adequate urine output and their BUN and creatinine levels stabilize. Because the development of ATN after transplantation surgery mimics the symptoms of rejection of the transplanted kidney, clients have to undergo a biopsy to determine the correct diagnosis. Immunosuppressive medication therapy is essential after kidney transplantation to protect the new kidney.

A nurse is teaching a client who has CAD about the difference between angina pectoris and MI. Which of the following should the nurse identify as indications of MI? SATA. a. N/V b. Diaphoresis and dizziness c. Chest and left arm pain that subsides with rest d. Anxiety and feelings of doom e. Bounding pulse and bradypnea

A, B, D

A nurse is assessing a client with a closed head injury who has received mannitol for manifestations of increased intracranial pressure (ICP). Which of the following findings indicates that the medication is having a therapeutic effect? A. The client's serum osmolarity is 310 mOsm/L. B. The client's pupils are dilated. C. The client's heart rate is 56/min. D. The client is restless.

A. The client's serum osmolarity is 310 mOsm/L. Mannitol is an osmotic diuretic used to reduce cerebral edema by drawing water out of the brain tissue. A serum osmolarity of 310 mOsm/L is desired. A decrease in cerebral edema should result in a decrease in ICP.

A nurse is assessing for disseminated intravascular coagulation (DIC) in a client who has septic shock secondary to an untreated foot wound. Which of the following findings should the nurse expect? (Select all that apply.) A. Bradycardia B. Bleeding at the venipuncture site C. Petechiae on the chest and arms D. Flushed, dry skin E. Abdominal distension

B C E The formation of large amounts of microemboli in the circulation depletes the body's platelets and clotting factors. As a result, uncontrollable bleeding can occur, as manifested by bleeding at the venipuncture site, petechiae on the chest and arms, and bleeding in the abdominal cavity resulting in abdominal distension due to internal bleeding.

A nurse is preparing a client who is scheduled to have an arthroscopy the following day. Which of the following statements indicates that the client understands the pre-procedure teaching? A. "I have to keep my leg straight throughout the whole procedure." B. "The doctor will be able to see if I have signs of rheumatoid arthritis." C. "I should expect to stay overnight until I can walk around." D. "I'll have a scar that will be about an inch long."

B. "The doctor will be able to see if I have signs of rheumatoid arthritis." An arthroscopy helps with diagnosing musculoskeletal disorders such as rheumatoid arthritis, osteoarthritis, and internal joint injuries.

A nurse in an emergency department is assessing a client who sustained a fall off of a roof. Which of the following findings should the nurse identify as an indication of a basilar skull fracture? A. Depressed fracture of the forehead B. Clear fluid coming from the nares C. Motor loss on one side of the body D. Bleeding from the top of the scalp

B. Clear fluid coming from the nares Cerebrospinal fluid manifests as a clear fluid coming from the nares or ears, indicating a basilar skull fracture.

A nurse is caring for a client who is 2 days postoperative. Which of the following findings indicates that the client is developing an infection? A. Temperature 37.8°C (100°F) B. Erythema at the incision site C. WBC count 9,000/mm^3 D. Pain reported as 6 on a scale of 0 to 10

B. Erythema at the incision site Redness at the incision site is an initial sign of a wound infection and requires intervention by the nurse.

A nurse is caring for a client who is taking streptomycin. Which of the following medications increases the client's risk of developing ototoxicity when taken with streptomycin? A. Cefoxitin B. Furosemide C. Naproxen D. Amphotericin B

B. Furosemide Furosemide, a high-ceiling (loop) diuretic, increases the risk of developing ototoxicity when taken with streptomycin, an aminoglycoside.

A nurse is planning care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan of care? A. Restrict fluids to 1,000 mL per day B. Measure the client's abdominal girth daily C. Check IV sites every 4 hr for bleeding D. Administer an enema as needed for constipation

B. Measure the client's abdominal girth daily The nurse should measure the client's abdominal girth daily to monitor for manifestations of internal bleeding. A client who has a reduced platelet count is at risk of bleeding due to delayed clotting.

A nurse is preparing to administer an IM injection for a client. Which of the following factors should the nurse identify as a potential contraindication to administering the medication via the IM route? A. The medication is a depot preparation. B. The client is taking an anticoagulant. C. The medication is a particulate suspension. D. The client has been vomiting.

B. The client is taking an anticoagulant. Because of the risk of bleeding from the injection site, anticoagulant therapy (e.g. warfarin) is a contraindication to receiving medications via the IM route.

A nurse is talking with a group of women at a community center about the current recommendations for early detection of breast cancer. The nurse should explain which of the following options? A. Begin monthly breast self-examinations at age 40 B. Have a clinical breast examination each year after age 30 C. Begin annual mammograms at age 40 D. Have breast magnetic resonance imaging every 5 years after age 50

C. Begin annual mammograms at age 40 Women should begin performing monthly breast self-examinations at 20 years of age. From 20 to 39 years of age, women should undergo a breast examination by a health care provider every 3 years. Women older than 40 years of age should have annual breast examinations by a health care provider and an annual mammogram.

A nurse is assessing a client who has a fractured left femur and is in skeletal traction. Which of the following findings should the nurse report to the provider? A. Ecchymosis of the thigh B. Serous drainage at the pin site C. Chest petechiae D. Muscle spasms in the left leg

C. Chest petechiae The nurse should identify chest petechiae as an indication of fat embolism syndrome. Clients who have fractures of the long bones such as the femur are at increased risk of fat emboli. Fat emboli typically occur 12 to 48 hours after the injury when fat droplets from the marrow enter into the systemic circulation and are deposited in the lungs. The nurse should immediately notify the provider because the client could progress to acute respiratory failure.

A nurse is teaching a client how to perform range-of-motion exercises of the wrist. To perform adduction, which of the following instructions should the nurse include? A. "With your palm facing down, move your wrist sideways toward your thumb." B. "Move your palm toward the inner part of your forearm." C. "With your palm facing down, move your wrist sideways toward your little finger." D. "Bring the back of your hand as far back toward the wrist as you can."

a. "With your palm facing down, move your wrist sideways toward your thumb." This motion describes adducting the wrist. The client should be able to move her wrist 30º to 50º with this motion.

A nurse is providing education to a client who is to undergo an EEG the next day. Which of the following info should the nurse include in the teaching? a. "Do not wash your hair the morning of the procedure." b. "Try and stay awake most of the night prior to the procedure." c. "The procedure will take approximately 15 mins." d. "You will need to lie flat for 4 hours after the procedure."

b. "Try and stay awake most of the night prior to the procedure." Tell the client to remain awake to provide cranial stress and increase the possibility of abnormal electrical activity

A nurse is reviewing the lab results of a lumbar puncture for a client who has manifestations of bacterial meningitis. Which of the following findings should the nurse expect? a. Elevated glucose b. Elevated protein c. Presence of RBCs d. Presence of D-dimer

b. Elevated protein Manifestations of bacterial meningitis include increase protein in the CSF, decreased glucose. RBCs can indicate bleeding, however, WBCs are what indicates bacterial meningitis.

A nurse is preparing an in-service program about the stages of acute kidney injury. Which of the following pieces of info should the nurse include about prerenal azotemia? a. Prerenal azotemia begins prior to the onset of symptoms b. Interference with renal perfusion causes renal azotemia c. Prerenal azotemia is irreversible, even in early stages d. Infections and tumors cause prerenal azotemia

b. Interference with renal perfusion causes prerenal azotemia. Prerenal = interference with renal perfusion, such as from heart failure or hypovolemic shock.

A nurse is preparing a client who has a brain tumor for a CT scan. Which of the following factors affects the manner in which the nurse will prepare the client for the scan? a. No food or fluids consumed for 4 hours b. Difficulty recalling recent events c. Development of hives while eating shrimp d. Paresthesia in both hands

c. Development of hives while eating shrimp Shellfish allergy is contraindication of use of contrast media during a CT scan.

A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following findings should the nurse report to the provider? a Output equal to the instilled irrigate b. Client reports bladder spasms c. Viscous urinary output with clots d. Reports of strong urge to urinate

c. Viscous urinary output with clots Urine that is bright red with clots is an indication of arterial bleeding.

A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include? A. Blow into the spirometer to elevate the balls in the device B. Cough deeply after each use C. Clean the mouthpiece with an alcohol swab after each use D. Use the spirometer every 8 hr

B. Cough deeply after each use Proper use of the incentive spirometer loosens secretions in the client's lungs. The client should cough deeply to facilitate the removal of secretions from his lungs. A. The nurse should instruct the client to inhale deeply to elevate the balls in the device. C. The nurse should instruct the client to clean the mouthpiece with water and dry it after each use. D. The nurse should instruct the client to use the spirometer several times every hour while awake.

A nurse is teaching a female client with a new diagnosis of systemic lupus erythematosus (SLE) about factors that can trigger an exacerbation of SLE. The nurse should determine that the client requires further teaching if she identifies which of the following as an exacerbation factor? A. Exercise B. Pregnancy C. Infection D. Sunlight

A. Exercise SLE is a chronic autoimmune disease that develops when the immune system becomes hyperactive and attacks healthy body tissue. This attack results in generalized inflammation and creates manifestations associated with the specific involved tissues. Most clients who have SLE can follow an exercise program to increase their cellular aerobic capacity and improve immune function, and the client should follow a program with her provider's assistance. This client needs additional teaching about the importance of exercise to keep her muscles and joints active.

A nurse is implementing cold therapy for a client who has an ankle sprain. Which of the following actions should the nurse take? A. Apply a cold pack to the edematous area B. Check capillary refill before applying an ice pack to the affected area C. Half-fill an ice pack with crushed ice D. Apply an ice pack for 60 min intervals

B. Check capillary refill before applying an ice pack to the affected area The nurse should check the affected area for adequate circulation by assessing pulses and capillary refill because a cold pack applied to an area of impaired circulation can further decrease the blood supply to the area.

An emergency room nurse is assessing a client who has a new traumatic brain injury. The nurse observes extension of the client's arms and legs, pronation of the arms, and plantar flexion of the feet. Which of the following actions is the nurse's priority? A. Monitor urinary output B. Administer an osmotic diuretic C. Provide supplemental oxygen D. Initiate seizure precautions

C. Provide supplemental oxygen The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to provide supplemental oxygen. The client might require an artificial airway and mechanical ventilation because these findings indicate decerebrate positioning, which is associated with brainstem injury and can lead to brain herniation and death.

A nurse is planning care for a client who has AIDS and has developed stomatitis. Which of the following interventions should the nurse include in the plan of care? A. Rinse the mouth with chlorhexidine solution every 2 hr B. Limit fluid intake with meals C. Provide oral hygiene with a firm-bristled toothbrush after each meal D. Avoid salty foods

D. Avoid salty foods Stomatitis is an inflammation of the mucosa of the mouth, usually with ulcerations. Foods that are spicy, acidic, or salty should be avoided to prevent further irritation and damage to the oral mucosa.

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?: a. Headache b. Infection c. Aphasia d. Hypertension

b. Infection Monitor for infection and use strict asepsis to avoid life-threatening meningitis.

A nurse is monitoring the ECG of a client who has hypocalcemia. Which of the following findings should the nurse expect? a. Flattened T waves b. Prolonged QT intervals c. Shortened QT intervals d Widened QRS complexes

b. Prolonged QT intervals Manifestations of hypocalcemia include tingling, numbness, tetany, seizures, prolonged QT intervals, and laryngospasm.

A nurse is preparing a client for a bronchoscopy. Which of the following actions should the nurse take? (Select all that apply.) A. Explain that the client will receive sedation and will not remember the procedure. B. Verify that the client understands the purpose and nature of the procedure. C. Offer the client sips of clear liquids until 1 hr before the test. D. Obtain a pre-procedural sputum specimen. E. Instruct the client to keep his neck in a neutral position.

A. Explain that the client will receive sedation and will not remember the procedure. B. Verify that the client understands the purpose and nature of the procedure. For a bronchoscopy, clients typically receive premedication with a benzodiazepine or an opioid to ensure sedation and amnesia. The client will have signed a consent form, so the nurse should verify that the provider explained the procedure and that the client understands it.

A nurse is caring for a client who had a cerebrovascular accident (CVA). The client appears alert and engaged during a visit but does not respond verbally to questions. The nurse should document this as which of the following alterations? A. Expressive aphasia B. Dysarthria C. Receptive aphasia D. Dysphagia

A. Expressive aphasia A client who has expressive aphasia understands speech but has difficulty speaking and writing. This typically occurs as a result of a lesion at Broca's area of the frontal lobe.

A nurse is providing discharge instructions to a client who is postoperative following surgical excision of a basal cell carcinoma. Which of the following findings should the nurse include as an indication of a mole's potential malignancy? A. Ulceration B. Blanching of surrounding skin C. Dimpling D. Fading of color

A. Ulceration Ulceration, bleeding, and exudation are indications of a mole's potential malignancy. Increasing size is also a warning sign. The nurse should emphasize the importance of lifetime follow-up evaluations and the proper techniques for self-examination of the skin every month.

A nurse is teaching a client who has persistent cancer pain about the adverse effects of opioids. Which of the following statements should the nurse include in the teaching? A. "Opioids do not relieve pain without causing severe adverse effects." B. "Physical dependence is not the same as addiction." C. "Tolerance typically means that the medication will no longer be effective." D. "The most common adverse effect is respiratory depression with prolonged use."

B. "Physical dependence is not the same as addiction." The nurse should explain that physical dependence can occur in all clients who take opioids, and the client may develop abstinence syndrome if the opioid is abruptly withdrawn. Physical dependence is not the same as addiction, but it can result in addiction. Addiction results when the opioid is continued despite physical or psychological harm.

A nurse is providing discharge teaching to a client who has a new permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching? A. "I should check my heart rate at the same time each day." B. "I don't have to take my antihypertensive medications now that I have a pacemaker." C. "I should keep a pressure dressing over the generator until the incision is healed." D. "I cannot stand in front of our new microwave oven when it is on."

A. "I should check my heart rate at the same time each day." The nurse should instruct the client to check the heart rate at the same time each day and to document the rate in a log for reporting to the provider. Incorrect Answers: B. A pacemaker maintains a regular heart rate but is not intended to lower blood pressure or control hypertension. C. The client should avoid applying pressure over the generator. D. New microwaves are equipped with shielding that protects a person who has a pacemaker from interference. Hence, standing in front of a new microwave oven is not contraindicated. The client should avoid being in close proximity to older microwaves that do not have this shielding.

A charge nurse is observing a newly licensed nurse administer an IV medication to a client who has an implanted venous access port. Which of the following observations requires intervention by the charge nurse? A. A dressing is not applied to the port site after use. B. A 22-gauge non-coring needle is used to access the port. C. Blood return is noted prior to administering the medication. D. A solution of 5 mL heparin 1,000 units/mL has been prepared.

D. A solution of 5 mL heparin 1,000 units/mL has been prepared. Implanted ports should be flushed after each use and at least once a month when not in use. This practice is sometimes referred to as "locking" or "de-accessing." It is performed to prevent the formation of blood clots in the catheter, which would disrupt the proper functioning of the catheter. The solution of 5 mL heparin should be 100 units/mL; therefore, this action requires intervention by the charge nurse.

A nurse is completing an assessment for a client who has a history of unstable angina. Which of the following findings should the nurse expect? A. Chest pain is relieved soon after resting. B. Nitroglycerin relieves chest pain. C. Physical exertion does not precipitate chest pain. D. Chest pain lasts for longer than 15 min.

D. Chest pain lasts for longer than 15 min. A client who has unstable angina will have chest pain lasting longer than 15 minutes. This is due to reduced blood flow in a coronary artery from atherosclerotic plaque and thrombus formation causing partial arterial obstruction or from an artery spasm. Incorrect Answers: A. A client who has unstable angina will have chest pain even while resting because of insufficient blood flow to the coronary arteries and a decreased oxygen supply. Chest pain at rest is a condition called variant (Prinzmetal's) angina and is caused by an arterial spasm. B. A client who has unstable angina will have minimal, if any, relief of chest pain with nitroglycerin. C. A client who has unstable angina will report chest pain or discomfort with exertion, which can limit the client's activity.

A nurse is providing teaching to a client who has a new diagnosis of myasthenia gravis (MG). Which of the following pieces of information should the nurse include? A. Use enemas to treat constipation caused by daily medications B. Take a hot bath when muscles ache C. Eat a low-calorie diet D. Set an alarm to ensure medication dosages are taken on time

D. Set an alarm to ensure medication dosages are taken on time The nurse should instruct the client to take medication dosages on time to maintain a therapeutic blood level. Dosages should not be missed or postponed because this can cause an exacerbation of the disease.