Medsurg 2 ATI final prep questions

A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a Motor vehicle accident. Put these steps in order of priority Perform GCS assessment Open the airway using jaw thrust maneuver Remove clothing for a thorough assessment Establish IV access Determine the effects of the ventilator efforts

1. Open the airway using jaw thrust maneuver 2. Perform GCS 3. Establish IV access 4. Remove clothing for a thorough assessment 5. Determine the effects of the ventilator efforts

A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which statement is true? A. DIC is caused by abnormal coagulation involving fibrinogen B. DIC is characterized by an elevated platelet count

A. DIC is caused by abnormal coagulation involving fibrinogen

A nurse is preparing to transfer a client from a bed to a chair. Which of the following actions should the nurse take first? A. Determine if the client can bear weight B. Place the belt on the pt C. Position the bed at an appropriate height D. Assist the client to a seated position

A. Determine if the client can weight bear

RN is teaching a pt who has a prosthetic limb due to a right BKA about prosthesis and stump care. Which instructions should be in teaching? A. Dry the prosthesis socket completely before applying it into the limb B. apply a moisturizing lotion to the stump daily

A. Dry the prothesis socket completely before applying it into the limb

RN reviews the labs for a client who has atherosclerosis and notes elevated cholesterol levels. Which statement requires follow up on low chol diets? A. I eat two eggs for breakfast each morning B. I cook my food with canola oil C. I flavor my meat with lemon juice

A. I eat two eggs for breakfast each morning

A nurse is planning care for a client who is postoperative: thyroidectomy. Which of the following interventions should the nurse include? SATA A. Instruct the client to deep breathe every 4 hours B. Check the client's voice every 2 hours C. Placed the HOB flat D. Hyperextend the neck

A. Instruct the client to deep breathe every 4 hours B. Check the client's voice every 2 hours

A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm A. The P wave falls before the QRS complex B. The qrs duration is twenty seconds C. The T wave is inverted

A. The P wave falls before the QRS complex

A nurse is assessing a client who has hypokalemia d/t nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect? A. Weak, irregular pulse B. Hyperactive bowel sounds C. Hyperactive reflexes D. Extreme thirst

A. Weak, irregular pulse low potassium

An RN in the ED is caring for a pt with extensive partial and full-thickness burns of the head, neck, chest. Which assessment risk is priority? A. airway obstruction B. infection C. fluid imbalance D. paralytic ileus

A. airway obstruction

The RN finds the patient pulseless. The family has requested a DNR order from the MD, but he has not written the order yet. What action should the RN take? A. Call the emergency response team B. Seek immediate help from the risk manager C. Call the provider for a stat DNR order

A. call the emergency response team

A nurse is planning care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse include in the plan of care? A. decrease patients fluid intake B. increase their saturated fat intake C. increase their sodium intake D. Decrease the clients carbohydrate intake

A. decrease patients fluid intake

A nurse is giving a presentation about preventing deep-vein thrombosis (DVT). What risk factors should be included? SATA A. bmi of twenty B. oral contraceptive use C. hypertension D. high calcium intake E. Immobility

B and E

A nurse is admitting a client who has active tuberculosis to a room on M/S. Which of the following room assignments should the nurse make? A. A room with another nonsurgical client B. A room with air exhaust directly to the outdoor environment C. A room near nurses station

B. A room with air exhaust directly to the outdoor environment this is a negative pressure room

A nurse is teaching a middle-age client about hypertension. Which of the following information should the nurse include in the teaching? A. Reaching your goal blood pressure will occur within 2 months B. Diuretics are the first type of med to control htn C. Plan to lower your saturated fats to ten perfect of your daily caloric intake D. Limit your alcohol consumption to 3 drinks a day

B. Diuretics are the first type of med to control hypertension

RN in a health clinic is administering inactive flu vaccine. Before administering it, the nurse must confirm that the pt is not allergic to.... A. shellfish B. eggs C. gelatin D. yeast

B. Eggs shellfish is the contraindicated one for contrast dye

A nurse is assisting an older adult client who sometimes loses her balance while walking. Which of the following should the RN use while ambulating? A. Cane B. Gait belt C. Jacket harness D. Walker with four wheels

B. Gait belt

A nurse is caring for a pt with type 1 DM with c/o feeling shaky and having palpitations. Blood glucose in 48. RN gives the pt which of the following? A. 1 tsp sugar B. Graham crackers C. 4 oz diet soda D. 4 oz skim milk

B. Graham crackers they are hypoglycemic, we want to bring them up want to give them 15 grams of carbs

A nurse is planning care for a client who has diverticulitis. Which of the following menu selections should the nurse include in the plan? A. Turkey sandwich with celery sticks B. Grilled chicken breast with white rice C. Sliced ham with green salad D. Pork tenderloin with green peas

B. Grilled chicken breast with white rice

A nurse is teaching a client how to do fecal occult blood testing. Which statement by the client indicates a need for further teaching? A. I will continue my low dose aspirin therapy regimen B. I will continue taking my Coumadin as prescribed C. I will avoid steak and other red meats D. I will refrain from eating raw fruits and veggies

B. I will continue taking my Coumadin as prescribed coumadin will make you bleed but low dose aspirin is okay

An RN is instructing a pt how to decrease the nausea associated with chemotherapy and radiation. Which of the following statements from the patient indicates understanding? A. I will eat smaller meals if I feel nauseated B. I will eat foods that are served at room temperature C. I will drink more liquids with my meals D. I will increase the amount of unsaturated fats in my diet

B. I will eat foods that are served at room temperature A is wrong bc if youre nauseated youre not eating B is correct bc we don't want them eating foods with temps under room temp

A nurse is teaching a client who has hepatitis A. Which of the following information should the nurse include? A. Hepatitis A infects the kidneys B. Manifestations of the virus are similar to flu like sx C. The incubation of the virus is 5 days D. a family hx increases your risk for acquiring hepatitis A

B. Manifestations of the virus are similar to flu like sx the incubation period is weeks long and transmitted through fecal/oral

RN is caring for a client who is 1 day postop thyroidectomy and reports severe muscle spasms to lower extremities. Which action should the RN take? A. Check pedal pulses B. Verify the most recent calcium level C. Request prescription for a relaxant D. Administer an oral potassium supplement

B. Verify the most recent calcium level When they remove thyroid, it can mess with the parathyroid which can decrease the calcium levels

An RN is caring for a pt who is postop appendectomy. The surgeon prescribes a clear liquid diet. Which of the following should the nurse offer? A. broth B. grape juice C. nonfat milk D. custard E. lemon jello

Broth Grape juice Lemon jello

A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first? A. Reposition the client B. Administer the medication C. Determine the location of the pain D. Review the effects of the pain meds

C. Determine the location of the pain This is doing an assessment first, obtain more info first

A nurse is assessing a client at a dermatology clinic. Which of following findings places the client at risk for developing malignant melanoma A. Female B. Age 19 to thirty C. Chronic skin irritation history D. Dark hair

C. chronic skin irritation history

RN removes an indwelling urinary catheter that an older adult pt had in place 2 days. RN will assess for which expected outcome after catheter removal? A. blood tinged urine B. urinary frequency for several days C. temporary urinary retention D. highly concentrated urine

C. temporary urinary retention 4 hours of no pee is acceptable, after that get a bladder scanner and may need in and out highly concentrated urine means dehydration urinary frequency for days means uti

A nurse in an ED is caring for a client who has diabetic ketoacidosis (DKA) and a blood glucose level of 925 mg/dL. The RN anticipates which order? A. glucocorticoid meds B. Dextrose 5% in .45% sodium chloride C. Oral hypogylcemic meds D. 9% sodium chloride IV bolus

D. 9% sodium chloride IV bolus once they're on the iv insulin and were bringing down the sugar, then we give them dextrose

An RN is assisting a pt who has received crutches in an UC following a foot injury. Which of these statements indicates need for further teaching? A. i will keep spare crutch tips handy B. I will bear the weight of my body on my hands C. I will inspect my crutches everyday for signs of wear D. I have a set of my brothers crutches in the basement I can also use

D. I have a set of my brothers crutches in the basement I can also use this statement indicates a need for further teaching