Med Surg ATI Proctored Practice

A nurse is teaching a client with arthritis who is experiencing joint pain that impairs mobility. Which of the following instructions should the nurse include?

"Apply heat to your joints prior to exercising."

A nurse is caring for a client who has systemic lupus erythematosus (SLE) and is concerned about skin lesions on her face and neck. The client asks the nurse, "What should I do about these spots?" Which of the following responses should the nurse give?

"Apply moisturizer cream twice per day until scabs form on the lesions."

A nurse is teaching a client who has polycythemia vera about self-care measures. Which of the following interventions should the nurse include?

"Elevate your legs when sitting."

A nurse in a provider's office is teaching a client with a recent diagnosis of rheumatoid arthritis who has a new prescription for naproxen tablets. Which of the following statements by the client indicates the need for further teaching?

"I can take this medication with aspirin."

A nurse is providing discharge teaching to a client who is post-operative following a right mastectomy for breast cancer. The client will be discharged with 2 Jackson-Pratt drains. Which of the following pieces of information should the nurse include in the teaching?

"The drainage tubes often are removed at the same time as the stitches."

A nurse is caring for a client who had a below-the-knee amputation for gangrene of the right foot. The client reports sensations of burning and crushing pain in the toes of the absent right foot. Which of the following statements should the nurse make?

"This type of pain usually decreases over time as the limb becomes less sensitive."

A nurse is preparing a client for magnetic resonance imaging (MRI) of the spine. Which of the following pieces of information should the nurse give the client prior to the procedure?

"You can have a mild sedative before the procedure."

A nurse is providing discharge teaching to a client who is postoperative following scleral buckling to repair a detached retina. Which of the following instructions should the nurse include in the teaching?

"You should avoid reading for 1 week."

A nurse is providing teaching to a client who is preoperative for a renal biopsy. Which of the following statements should the nurse make?

"You will need to be on bed rest following the procedure."

A nurse is assessing the hematologic system of an older adult client. The nurse should report which of the following findings to the provider as a possible indication of a hematologic disorder?

Absence of hair on the legs

A nurse is rewarming a client following coronary artery bypass graft (CABG) surgery. For which of the following complications of the rewarming process should the nurse monitor the client?

Acidosis

A nurse is caring for a client who has moderate Alzheimer's disease. Which of the following actions should the nurse take?

Add gestures when speaking with the client

A nurse is assessing a client who is in the early stages of hepatitis A. Which of the following manifestations should the nurse expect?

Anorexia

A nurse is teaching a client who has genital herpes about self-management. Which of the following instructions should the nurse include in the teaching?

Apply a warm compress to the lesions

A nurse is caring for a client who is 72 hr postoperative following an above-the-knee amputation. Which of the following actions should the nurse take?

Assist the client into a prone position every 4 hr

A nurse is reviewing the medical record of a client who has heart failure. Which of the following findings should the nurse expect?

BNP of 200 pg/mL

A nurse is planning care for a client who is postoperative following a radical mastectomy. Which of the following interventions should the nurse include in the plan?

Begin exercises with the client 1 day after the procedure

A nurse is triaging clients during a mass casualty event. Which of the following labels should the nurse assign to a client who has a head injury with fixed, dilated pupils?

Black tag

A nurse is assessing for disseminated intravascular coagulation (DIC) in a client how has septic shock secondary to an untreated foot wound. Which of the following findings should the nurse expect? Select all that apply.

Bleeding at the venipuncture site Petechiae on the chest and arms Abdominal distention

A nurse is preparing to administer packed RBCs to a client who is anemic. Which of the following actions should the nurse take? Select all that apply.

Check to determine the packed RBCs are less than 1 week old Ask another nurse to check the packed RBCs' label against the medical record Prime the transfusion tubing with 0.9% sodium chloride

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) therapy and has just returned to the room following physical therapy. The nurse notes that the infusion pump, the nurse should monitor the client for which of the following findings?

Diaphoresis

A nurse is performing a neurological assessment for a client who has a brain tumor. Which of the following findings should indicate cranial nerve involvement?

Dysphagia

A nurse is assessing a client who has pericarditis. Which of the following manifestations should the nurse expect?

Dyspnea with hiccups

A nurse is caring for a client for whom the respiratory therapist has just removed the endotracheal tube. Which of the following actions should the nurse take first?

Evaluate the client for stridor

A nurse is preparing a client for a bronchoscopy. Which of the following actions should the nurse take? Select all that apply.

Explain that the client will receive sedation and will not remember the procedure Verify that the client understands the purpose and nature of the procedure

A nurse is caring for a client who has lung cancer that has metastasized. Which of the following findings indicates the client is developing superior vena cava syndrome?

Facial edema

A nurse is providing dietary teaching to a client who has diverticulitis about preventing acute attacks. Which of the following foods should the nurse recommend?

Foods high in fiber

A nurse is caring for a client with a history of cirrhosis who has been admitted with manifestations of hepatic encephalopathy. The nurse should anticipate a prescription for which of the following laboratory tests to determine the possibility of recent excessive alcohol use?

Gamma-glutamyl transferase (GCT)

A nurse is assessing a client who is receiving hemodialysis for the first time. Which of the following findings indicates that the client is developing dialysis disequilibrium syndrome (DDS)?

Headache

A nurse is caring for a client who is experiencing an acute exacerbation of rheumatoid arthritis. The nurse should anticipate that the client's affected joints will require which of the following treatments?

Heat paraffin therapy applied to the client's joints

A nurse is caring for a client who has been diagnosed with an Addisonian crisis and has a blood pressure of 74/42 mmHg. Which of the following prescriptions should the nurse anticipate?

Hydrocortisone

A nurse is assessing a client who is bedridden and was admitted from home. The nurse notes a shallow crater in the epidermis of the client's sacral area. The nurse should document that the client has a pressure ulcer at which of the following stages?

II (2)

A nurse names 3 objects for the client to remember, asks the client to repeat them, and tells the clients he will have to repeat them again in a few minutes. After 5 min, the nurse asks the client to name the objects. The nurse is using this strategy to test which type of memory?

Immediate

A nurse is caring for a postmenopausal client who is concerned that she might have an elevated risk of breast cancer. After conducting a risk assessment, the nurse should identify which of the following factors as increasing the client's breast cancer risk? Select all that apply.

Increased breast density BMI of 32 Undergoing hormonal replacement therapy

A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect?

Lower back discomfort

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?

Lung cancer usually has metastasized before the client presents with symptoms

A nurse is providing dietary teaching to a client who has dumping syndrome following gastric bypass surgery 4 days ago. Which of the following recommendations should the enurse include in the teaching?

Maintain a supine position after meals

A nurse is planning care for a client for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan of care?

Measure the client's abdominal girth daily

A nurse is caring for a client who has chronic phantom limb pain following an above-knee amputation. Which of the following medication prescriptions should the nurse verify with the provider?

Meperidine

A nurse is caring for a client who is wearing a halo fixator. Which of the following interventions should the nurse implement? Select all that apply.

Monitor the client's vital signs every 4 hr MOnitor the client's pin sites for loosening Check the client's skin to ensure the jacket is not applying pressure

A nurse is teaching a client who has coronary artery disease about the difference between angina pectoris and myocardial infarction (MI). Which of the following manifestations should the nurse identify as indications of MI? Select all that apply.

Nausea and vomiting Diaphoresis and dizziness Anxiety and feelings of doom

A nurse is assessing a client who has acute kidney injury (AKI). According to the RIFLE classification system, which of the following findings indicates that the client has end-stage kidney disease?

No urine output without renal replacement therapy for more than 3 months

A nurse is admitting a client who has cirrhosis. Which of the following prescriptions should the nurse anticipate? Select all that apply.

Obtain the client's PT and INR measurements Administer lactulose 30 mL PO 4 times daily Obtain daily weight and abdominal girth measurements Administer a daily multivitamin

A nurse is preparing to administer cisplatin IV to a client who has lung cancer. The nurse should identify that which of the following findings is an adverse effect of this medication?

Tinnitus

A nurse is planning care for a client who has syndrome of inappropriate antidiuretic hormone secretion (SIADH) with mild manifestations. The nurse should expect the provider to prescribe which of the following medications?

Tolvaptan

A nurse is providing teaching to a client who has Addison's disease about healthy snack foods. Which of the following food choices by the client indicates an understanding of the teaching?

Turkey and cheese sandwich

A nurse is providing discharge teaching to a client who had a sickle cell crisis. Which of the following statements indicates that the client understands the instructions?

"Physical activity is good for me, but I need to avoid overexertion."

A nurse is caring for a client who has a prescription for silver sulfadiazine cream to be applied to her burn wounds. The nurse should evaluate the client for which of the following laboratory findings?

Leukopenia

A nurse is reviewing a client's repeat laboratory results 4 hr after administering fresh frozen plasma (FFP). Which of the following laboratory results should the nurse review?

Prothrombin time

A nurse is reviewing the medical history of a client who has presbyopia. With which of the following activities should the nurse expect the client to have difficulty?

Reading the newspaper

A nurse is caring for a client who has diverticulitis. While the client has active inflammation, the nurse should instruct the client to include which of the following foods in her diet?

White bread and plain yogurt

A nurse is providing teaching to a client who has cervical cancer and is scheduled to receive brachytherapy in an ambulatory care clinic. Which of the following statements by the client indicates an understanding of the teaching?

"I need to lie still in bed during my brachytherapy treatment."

A nurse in a provider's office is reviewing the medical records of a group of clients. Which of the following clients is at risk for iron deficiency? Select all that apply.

A client who is vegetarian A client who is pregnant A toddler who is overnight

A nurse is monitoring the laboratory results of a client who has end-stage liver failure. Which of the following results should the nurse expect?

Increased prothrombin time

A charge nurse is observing a newly licensed nurse irrigate a client's ear, which is impacted with cerumen. Which of the following actions requires the charge nurse to intervene?

Instilling 50 mL of fluid with each irrigation

A nurse is planning postoperative education for a client who will undergo a radical neck dissection for cancer of the larynx. The nurse should include which of the following topics?

NPO status Alternative methods of communication Changes in body image Swallowing exercises

A nurse is determining a client's risk of developing osteoporosis. The nurse should identify which of the following as risk factors for bone loss? Select all that apply.

Small body frame Low vitamin D intake Smoking

A nurse is preparing an in-service presentation about assessing clients who are having an acute myocardial infarction (MI). What is the most common assessment finding with acute MI?

Substernal chest pain

A nurse is collecting a health history from a client. Which of the following findings is the highest risk factor for the client developing bladder cancer?

The client uses tobacco

A nurse is assessing a client who has urolithiasis and reports pain in his thigh. This finding indicates the stone is in which of the following structures?

Ureter

A nurse is preparing a client who is scheduled for an intravenous pyelogram (IVP). Which of the following findings should the nurse report to the provider?

Vomiting and diarrhea for the last 6 hr

A nurse is updating the plan of care for a client who is to receive total parenteral nutrition (TPN). Which of the following actions should the nurse include in the plan? Select all that apply.

Weigh the client daily Obtain a serum blood glucose every 4 hr Change the IV tubing every 24 hr

A nurse is providing preoperative teaching to a client who will undergo a total laryngectomy. Which of the following statements indicates that the client understands the impact of the surgery?

"I understand that I will have a permanent tracheostomy after the surgery."

A nurse is providing teaching about disease management to a client who has rheumatoid arthritis. Which of the following responses by the client indicates an understanding of the teaching?

"I will have handrails installed in my bathroom and hall."

A nurse is checking paradoxical blood pressure of a client who has a possible cardiac tamponade. In what order should the nurse complete the following steps?

1. Paplate the blood pressure and inflate the cuff above the systolic pressure 2. Deflate the cuff slowly and listen for the first audible sounds 3. Identify the first BP sounds audible on expiration and then on inspiration 4. Subtract the inspiratory pressure from the expiratory pressure 5. Inspect the jugular venous distention and notify the provider

A nurse is demonstrating colostomy care to a client who has a new colostomy. Which of the following actions should the nurse teach the client to perform? Select all that apply.

Empty the bag when it is one-third to one-half full Cut the skin barrier opening a little larger than the ostomy Wash the peristomal skin with mild soap and water

A nurse is providing teaching for a client following a below-the-knee amputation. Which of the following pieces of information should the nurse include in the teaching?

Instruct the client to lie prone while in bed

A nurse is monitoring a client following a thyroidectomy for the presence of hypoparathyroidism. Which of the following findings should the nurse expect?

Involuntary muscle spasms

A nurse is provider's office is assessing a client's skin lesions. The nurse notes that the lesions are 0.5 cm (0.20 in) in size, elevated, and solid with distinct borders. The nurse should document these findings as which of the following skin lesions?

Papules

A nurse is caring for a client whose wounds are covered with a heterograft dressing. In response to the client's questions about the dressing, the nurse explains that it is obtained from which of the following sources?

Pig skin

A nurse is caring for a client who is 3 days postoperative following a below-the-knee amputation. Which of the following actions should the nurse take?

Rewrap the residual limb with a bandage 3 times per day

A nurse is planning care for a client following placement of a chest tube 1 hr ago. Which of the following actions should the nurse include in the plan of care?

Tape all connections between the chest tube and drainage system

A charge nurse is observing a newly licensed nurse provide care for a client who is receiving internal radiation therapy for the treatment of cervical cancer. For which of the following actions by the newly licensed nurse should the charge nurse intervene?

Borrowing a dosimeter film badge from another nurse before entering the client's room

A nurse is caring for a client who has a fractures right hip. Which of the following types of traction should the nurse expect the client to have prior to hip arthroplasty surgery?

Buck's traction

A nurse is teaching a group of clients about skin cancer. The nurse should explain that basal cell carcinoma originates from which of the following tissues?

Epidermis

A nurse is providing discharge teaching to the partner of a client who has a new diagnosis of hepatitis A. Which of the following instructions should the nurse include in the teaching?

"Encourage her to eat foods that are high in carbohydrates."

A nurse is providing discharge teaching to a client who has aplastic anemia. Which of the following statements indicates that the client understands the instructions?

"I should eliminate uncooked foods from my diet for now."

A nurse is providing teaching to a client who has a diagnosis of hepatitis A. Which of the following statements by the client indicates an understanding of the teaching?

"I should stop eating raw clams."

A nurse is providing preoperative teaching for a client who is scheduled for total knee arthroplasty. Which of the following statements by the client indicates an understanding of the teaching?

"I should wear elastic stockings on both of my legs."

A nurse is teaching a client who has a spinal cord injury to perform intermittent urinary self-catheterization at home after discharge. Which of the following statements indicates that the client understands the procedure?

"I will perform intermittent self-catheterization every 2 to 3 hr."

A nurse is providing teaching to a client who has stomatitis due to chemotherapy and radiation therapy. Which of the following statements by the client indicates a need for further teaching?

"I will use lemon and glycerin swabs after meals."

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?

"The doctor will be able to see if I have signs of rheumatoid arthritis."

A client who just learned that he has variant (Prinzmetal's) angina asks the nurse how this type of angina compares with stable angina. Which of the following replies should the nurse make?

"Variant angina can cause changes on your electrocardiogram."

A nurse is teaching breathing techniques to a client who has emphysema. Which of the following statements indicates that the client understands the mechanics of pursed-lip breathing?

"When I breathe out through pursed lips, my airways don't collapse between breaths."

A nurse is preparing a client for an electroencephalogram (EEG). Which of the following pieces of information should the nurse share with the client?

"You'll begin by lying still with your eyes closed."

A nurse is caring for a client with a hip fracture who has Buck's extension traction in place. Which of the following pieces of information should the nurse give the client about this type of traction? Select all that apply.

"You'll have considerably less pain with the traction in place." "The traction will help decrease muscle spasms." "The weights act as a pulling force to keep you leg and hip still."

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?

Dysrhythmias

A nurse is teaching a client who has pernicious anemia. The nurse should encourage the client to increase consumption of which of the following food?

Eggs

A nurse is reviewing the laboratory results of a lumbar puncture (LP) for a client who has manifestations of bacterial meningitis. Which of the following findings should the nurse expect?

Elevated protein

A nurse is caring for a client who has a fractured hip and was placed in Buck's traction 4 hr ago. Which of the following actions should the nurse take?

Encourage the client to perform dorsiflexion of the affected extremity every 2 hr

A nurse is caring for a client who has percutaneous endoscopic gastronomy (PEG) tube and is receiving intermittent feedings. Prior to initiating the feeding, which of the following actions should the nurse take first?

Place the client in the semi-Fowler's position

A nurse is caring for a client who had a gastric resection to treat adenocarcinoma of the stomach. The client tells the nurse in the PACU that he does not remember why the surgeon said he had to have a tube in his nose. The nurse should explain that the NG tube serves which of the following purposes?

Prevents excessive pressure on suture lines

A nurse is providing discharge teaching to the family of a client who has a new diagnosis of a seizure disorder. The nurse should instruct the client's family to take which of the following actions first in the event of a seizure?

Protect the client's head

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?

Provide supplemental oxygen

During a neurological assessment, a nurse asks the client to name all of his children, their ages, and their birth dates. Which of the following types of memory is the nurse testing?

Remote

A nurse is assessing a client who has a new diagnosis of acute angle-closure glaucoma. The nurse should anticipate the client to report which of the following manifestations?

Severe eye pain

A nurse is evaluating the laboratory values of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse expect?

Sodium 132 mEq/L

A nurse is assessing the skin of a client who has frostbite. The client has small blisters that contain blood, and the skin of the affected area does not blanch. The nurse should classify this injury as which of the following?

Third-degree frostbite

A nurse is caring for a client following a right pleural thoracentesis. The nurse measures a total of 35 mL of purulent drainage. Which of the following findings should the nurse recognize as an indication of a tension pneumothorax? Select all that apply.

Tracheal deviation to the left Absent breath sounds on the right side Neck vein distension

A nurse is assessing a client who sustained a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure?

Widened pulse pressure