Med Surg ATI Practice Assessment A

a nurse manager is preparing to review medication documentation which a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?

A. "Use the complete name of the medication magnesium sulfate" - The Institute for Safe Medication Practices designates that nurses and providers write the complete medication name magnesium sulfate when documenting medications to avoid any misinterpretation of MgSO4 as MSO4, which means morphine sulfate

a nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? Select all that apply

A. B. E. - Place the client in a room with negative-pressure airflow is correct - wear gloves when assisting the client with oral care is correct - use antimicrobial sanitizer is correct. -Limit each visitor to 2-hr increments is incorrect. The nurse does not need to limit the client's visitors. However, the nurse should limit the client's presence outside the room and have him wear a surgical mask when he does leave the room. - Wear a surgical mask when providing client care is incorrect. The nurse should wear an N95 respirator during client care to meet the requirements of airborne precautions.

a nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, she hears the following sound. This sound indicates which of the following?

A. narrowed arterial lumen - arterial bruits are blowing sounds resulting from blood flowing through occluded or narrowed arteries

a nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?

B. Place the clients arm in a dependent position - The nurse should place the client's arm in a dependent position because the veins will dilate due to gravity.

a nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophebitis?

C. Calf swelling - Swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility.

The nurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home?

C. Ill check the wires and cables on my TV to make sure they are in good working order - Oxygen is a highly flammable gas. The client should make sure any electrical equipment in the room where she is using supplemental oxygen is functioning properly so it does not create any electrical sparks.

a nurse is caring for client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that his condition is a contraindication for which of the following therapies?

D. Acupuncture - The nurse should inform the client that the use of acupuncture is contraindicated for a client who has herpes zoster, or any skin infection, to prevent an open portal on the skin's surface, which could increase the risk of further infection.

a charge nurse is discussing the responsibility of nurses caring for clients who have C.diff infection. Which of the following information should the nurse include in the teaching?

D. Have family members wear a gown and gloves when visiting - nurses are responsible for ensuring that family members wear a gown and gloves to prevent the transmission of C.diff spores. Caregivers must also wear gowns and gloves.

a nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown?

D. Have the client use a trapeze bar when changing position - By using a trapeze bar to assist with re-positioning and transferring, the client avoids the friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for pressure-ulcer development.

a nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting?

D. Stand close to the cabinet when lifting it - this action keeps the cabinet close to the nurse's center of gravity and decreases back strain from horizontal reaching

a nurse is teaching an older adult who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend?

A. Walking Briskly - Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy.

a nurse is caring for a client who has had his diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray?

D. The egg - For a client who is prescribed a mechanical soft diet, the nurse should remove fried eggs from the meal tray. Fried eggs are not a part of a mechanical soft diet. Eggs that are poached or scrambled are allowed on a mechanical soft diet and are an acceptable replacement for this item.

a nurse is admitting a client who has influenza. Which of the following types of transmission precautions should the nurse initiate?

A. Droplet - droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis

a nurse is preparing to administer 0.5mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?

A. Gently shake the container of medication prior to administration - the nurse should gently shake the liquid medication to ensure the medication is mixed.

a nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheotomy. Which of the following actions should the nurse plan to take?

B. Select a suction catheter that is half the size of the lumen - the nurse should select a catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa.

a nurse in surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?

B. Wrap monitoring cords with stockinette and tape them in place - Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the client's skin by covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to secure them.

a nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect?

C. Rapid Heart rate - Tachycardia indicates fluid-volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days.

a nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration?

C. Skin blanching - skin blanching, edema, and coolness at the IV site indicate infiltration

a nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?

C. The client holds the cane on the stronger side of her body - the client should hold the cane on the stronger side of her body to increase support and maintain alignment

a nurse is reviewing a client's medication prescription, which reads, Digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse question?

C. The dose

a nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer SQ. Determine the correct order of the steps for this procedure.

The nurse should first inject air into the vial of NPH without touching the needle to the solution. Next, the nurse should inject air into the vial of regular insulin, and then withdraw the correct amount of the regular insulin. Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin. The nurse should follow these steps to prevent contaminating the regular insulin with NPH insulin.