Medsurg dynamic adaptive quizing

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

nurse in rehab is performing an assessment for a client who is recovering from a left-hemisphere stroke. which of the follwing findings should you expect A. reduced left sided function B. difficulty speaking C. impulsive behavior D. neglect of the left side of body

B. the left is the dominant side and responsible for language. will need speech therapy -will demonstrate hemiplegia of the right side because of pyramidal pathway crosses over at the base of the brain C-impulsive b happens from right hemis. left side hemis are cautious D-if recovering from right hemi then it can neglect the left

amputations pg 459 ati 2019 a nurse is caring for a client who is 3 days postoperative following a below the knee amputation. whihc of the following actions should the nurse take A. place client on a soft mattress B. Rewrap residual limb with bandage 3x per day C. aaist client into a prone position for 20 min q 8 hrs daily D. turn client q 4 hrs while in bed

B.is correct it keeps the bandage taught, which ensures the residual limb to shrink and it allows the nruse to check the skin for redness or skin breakdown. A IS WRONG: use firm matture to prevent contractures from developing. C. is wrong: should use prone position for 20 to 30 min q 3 to 4 hrs daily to prevent hip contractures from developing following surgery. D. is wrong. turn q 2 hrs

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? I II III IV

II Rationale: With a stage II pressure ulcer, there is a partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and can appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer might become infected. The client might report pain, and there might be a small amount of drainage.

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 clients risk? select all that apply.

Increased breast density BMI of 32 Undergoing hormonal replacement therapy for 10 years

A nurse is caring for a client who is receiving brachytherapy. Which of the following measures should the nurse contribute to the client's plan of care?

Keep the door to the client's room closed

a nurse is caring for a client who has a closed traumatic brain injury and is experiencing increased intracranial pressure (ICP). this increase in ICP is due to which of the following. A. decreased cerebral perfusion B. leakage of cerebral spinal fluid C. Rigid skull containing cranial contents D. Brain herniated into the brainstem

Rigid skull containing cranial contents A,D all result to death B is from a basilar skull fracture which is an oepn traumatic injury

A charge nurse is observing a newly licensed nurse administer an IV medication to a patient who has an implanted venous access port. Which of the following observations requires intervention by the charge nurse? A. dressing not applied to 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 l heparin 10,000 units/ml has been prepared

A solution of 5 ml heparin 10,000 units/ml has been prepared. you only need 5ml heparin 100 units/ml. 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.

client has manifestations of acute tubular necrosis (ATN) following a kidney transplantation. which intervnetsion should the nurse anticipate for this client A. Hemodialysis B. Biopsy C. Immunosuppression D. Balloon angioplasty E. Surgical repair

A,B, C may need dialysis until their BUN and Cr levels stabilize. Need a biopsy because the development of ATN after transplantation surgery mimics the symptoms of rejections. and immunosuppression medication therapy is essential after kidney transplantation

pg 370 med surg ati 2019 book a nurse is admitting a client who has cirrhosis. which of the following prescriptions should the nurse anticpate? SELECT ALL THAT APPLIES A PT and INR measurements B. Administer lacutulose 30 ml PO 4x daily C. obtain daily weight and abdominal girth measurements D. Administer daily multivitamin E. Place client on high protein diet

A,B,C,D Cirrhosis interferes with the liver's ability to produce clotting factors which places the client at risk for hemorrhage. The PT and INR would be prolonged Lactulose med will help get rid of ammonia in the body Will need to do daily weight and abdominal girth measurements. Girth would show whether if ascites is increasing. If it is then they would weigh more.

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 informaiton should the nurse give the client about this type of traction select all that apply A. will have less pain with traction in place B. will be in it for a week or so C. helps decrease muscle spasms D. weights act as a pulling force to keep your leg and hip still E. ahve to make sure the weights are just barely touching the floor

A,C,D pain is usually more severe without the traction. its short term adn the weights must stay suspended at all times and shouldnt touch the floor

providing discharge instructions to a basal cell carcinoma pt. which findings should 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, bleeidng, and exudation are signs, increased size, redness or swelling, darkening. C and D are not involved

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 client wear a surgical mask B. have the x ray techs take the x-ray in his room C. have the patient wear an n95 mask

A. have a client wear a surgical mask

A nurse is providing information to client who is scheduled for an exercise stress test. this indicates an understanding of the teaching. A. Wont drink coffee for hours prior to test B. can eat a light meal one hour prior to test C. can I have a cigarette up to 30 minutes prior D. will take heart medication on day of test

A. is correct you cant have coffee, alcohol, or caffeine on the day of the test. they can affect HR and BP during it. B. should eat 2 hrs prior C. avoid smoking the entire day of the test D. BB or CCB are usually withheld the day of the test.

a nurse is monitoring a client following a thyroidectomy for the presence of hypoparathyroidism. which of the following findings should nurse expect A. Elevated bp B. involuntary muscle spasms C. COld intolerance D. weight loss

B. hypertension is an indication of thyroid storm. cold intolerance and weight loss shows hypothyroidism

patient has thrombocytopenia. which intervention should be included A. restricting fluids to 1,000ml B. measure girth daily C. Check iv sites every 3 hrs for bleeidng D. Administer enema as needed for constipation

B. to monitor for internal bleeding. never restrict fluid, check iv site q 2 hrs. no enema

pt has extensive burns, including on her face. which assessment is done first A. estimation of burn B. characteristics of cough and sputum C. extend of peripheral edema D. amt of UO

B. airway first

A nurse is teaching a client with Addison's disease about appropriate snack foods. The nurse evaluates the teaching to be effective when the client identifies which of the following as an appropriate snack food? A. sliced bananas B. baked potato C. Turkey and cheese sandwich D. plain yogurt with peaches

C its high in protein, carbs, and sodium. they need low K. A,B, D have high K

discharge teaching for a client with a newly inserted permanent pacemaker. which instructions should the nurse include in the teaching A. request providers Rx when traveling to alert airport security B. stand at least 3 ft away while using a microwave C. keep your cell phone 6 inches away from your pacemaker when making a call D. avoid showering for the first 2 weeks following surgery

C. A-dont need it B-microwave already has the shielding D-dont stand directly under shower or submerge or it will get extremely wet

A nurse is providing preoperative teaching for a client who has colorectal cancer and is to undergo placement of a colostomy with a perineal wound. Which of the following statements by the client indicates an understanding of the teaching?A. "It will be a relief to not have any further rectal pain."B. "I will need to sit on a rubber donut when I am out of bed in the chair."C. "I can have only liquids for 2 days before the surgery."D. "The colostomy will start working about 7 days after the surgery." A. not having any mroe rectal pain will be a relief B. I will need to sit on a donut when i am in a chair C. "I can have only liquids for 2 days before the surgery." D. the colostomy will start working about 7 days after surgery

C. "I can have only liquids for 2 days before the surgery."The client should consume a full or clear liquid diet for 24 to 48 hr before the surgery to decrease bulk. The client should consume a low-residue diet for several days prior to surgery to decrease peristalsis. rectal sensations like pain and itching can occur. should sit on foam pads or soft pillows, avoid donut devices, which increase pressure colostomy should function within 2 to 4 days

A nurse is providing discharge teaching to a client who is postoperative following a right mastectomy for breast cancer. The client will be discharged with two Jackson-Pratt drainage tubes. Which of the following information should the nurse include in the teaching? A. "Empty the drainage tubes once per day." B. "Showering is permitted before the drainage tubes are removed." C. "The drainage tubes often are removed at the same time as the stitches." D. "Do not begin exercising the arm until the provider removes the drainage tubes."

C. "The drainage tubes often are removed at the same time as the stitches."The nurse should instruct the client that the provider will remove the drainage tubes at the same time the stitches are removed, usually within 7 to 10 days.

a nurse is caring for a client who has systemic lupus erythematosus 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 (pg 577 ati) A. "keep the lesions covered with a light sterile dressing when going outdoors." B. Rub lsesions with a washcloth to dry after washing C. apply moisturizer after bathing the lesions with warm water D. apply anb cream 2x per day until scabs form on the lesions.

C. apply moisturizer after bathing lesions with warm water. should instruct them to clean, dry, and moisturize the skin using warm water and an unscented lotion A. is wrong: should wear a hat and protective clothing when outside. most often, the lesions are dry adn scaly, not open and draining. B is wrong. you dont rub lesions, you pat them dry D. is wrong: you use topical corticosteroid creams, not ANB for cutaneous manifestations of SLE

a nurse is preparing a client for discharge who is postoperative following a conventional lumbar disk excision. which of the following statements indicates tht the client understands the nurses instructions A. have no problem climbin stairs when i get home b. wait 3 weeks before returning to usual activities C. use heating pad for muscle spasms D. can go back to driving in 2 weeks or so.

C. is right. applying heat relaxes paraspinal muscles and reduces spasms A. will be limited to climbing but can walk right away B. may take up to 6 weeks to heal D. Driving adds flexion, so 6 weeks

A nurse is caring for a client who is postoperative following a urinary diversion to treat bladder cancer. which of the following interventions should the nurse include in the plan of care?

Change the collection pouch in the early morning

according to the RIFLE classification system, which of the following findings indicates that the client has end stage kidney disease? A. <0.5 ml of urine in 12 hrs B. no urine output for 12 hrs C. No urine output with renal replacement therapy for 4 to 12 weeks D. No urine output with renal replacement therapy for more than 3 months

D. A is injury B. is failure C loss

A nurse is assisting in the care of a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should plan to administer which of the following IV solutions? A. 0.45% NaCl B. D5 in 0.9% NaCl C. D10W D. 0.9% NaCl

D. 0.9 sodium chloride and LR are used for fluid volume replacement. A is hypotonic and will cause cells to swell B and C are hypertonic solution. no effect

nurse is caring for a client who will receive brachytherapy to treat uterine cancer. the nurse should ensure client understands that she will receive which of the following interventions A. chemotherapy via a central venous access device B. radiation to the tumor from an external source C. Precise delivery of high-dose radiation after tumor imaging D. Radioactive infusions or insertions into or near the tumor

D. radioactive infusion insertions into or near the tumor A is a chemical approach to kill cancer. brachy is not chemotherapy B. radiation of external source it teletherapy C. precise delivery of high-dose radiation is stereotactic body radiotherapy

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

increased PTT

a nurse is preparing a client for cardiac catheterization. which of the following pieces of information should the nurse give the client before the procedure

-he/she may feel a fluttery feeling as the catheter passes through the heart; a flushed warm feeling when the dye is injected; a desire to cough; and palpitations caused by heart irritability

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? the steps are in relation to how to do a blood pressure reading

1. palpate the BP and inflate the cuff above the SBP 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 for JVD distension and notify HCP

A nurse in the emergency department is assessing a client for a closed pneumothorax and significant bruising of the left chest following a motor-vehicle crash. The client reports severe left chest pain on inspiration. The nurse should assess the client for Which of the following manifestations of pneumothorax? a. absence of breath sounds b. expiratory wheezing c. inspiratory stridor d. rhonchi a. absence of breath sounds

A

a nurse is teaching a client who has acute pyelonephritis. instructions? A. complete full round of ANB B. should be on complete bedrest until manifestations disappear C. drink 1,000ml a day D. dont take NSAID for pain

A. balance rest and activity. ambulation can prevent complications should drink at least 2,000ml per day can take NSAIDS for pain

A nurse is preparing to administer packed RBC to a client who is anemic. Which of the following actions should the nurse take? select all that apply A. insert a 23-gauge angiocatheter with an iv adaptor B. Check to determine the packed RBC are less than 1 week old C. administer it over a 6 hr period D. ask another nurse to check the packed RBC labels against the medical records E. prime the transfusion tubing with 0.9% sodium chloride

B,D,E

A nurse caring for a client who has ulcerative colitis. The provider prescribes bed rest with bathroom privileges. When the client asks the nurse why he has to stay in bed, which of the following responses should the nurse provide? a."You need to conserve energy at this time." b."Lying quietly in bed helps slow down the activity in your intestines." c."Staying in bed promotes the rest and comfort you need." d."Staying in bed will help prevent injury and minimize your fall risk."

B. Lying quietly in bed helps slow down the activity in your intestines."Rationale: The greatest risk to the client is complications from severe diarrhea such as dehydration, electrolyte imbalances, and gastrointestinal bleeding and trauma. Activity restriction can help reduce intestinal peristalsis and diarrhea.

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 semi-Fowler's position. C. Cleanse the skin around the tube site. D. Aspirate the tube for residual contents.

B. semi fowler. all should be done, but sitting up is fisrt

During a neurological assessment, a nurse asks how the client arrived at the appointment and with whom. which of the following types of memory is the nurse testing A. Remote B. Immediate C. Recall D. Past

C. Recall this is recent memory. Remote is wrong: you would ask client to provide info from distant past like city of birth or the schools he attended> past memories Immediate is wrong: this is new memory, the nurse should give client 3 unrelated words, ask him to repeat them, and then ask to repeat later. Past is wrong: should ask for client's mother's maiden name or specific important date in history

a nurse is preparing an in service presenation about assessing clients who are having an acute myocaridal infarction. what is the most common assessment finding with acute MI A. dyspnea B. pain in shoulder and left arm C. substernal chest pain D. palpitations

C. substernal chest pain all the rest are manifestations

what are signs of DVT

Hardening along the blood vessle tenderness in the calf Increased leg circumference warm skin NOT absence of peripheral pulse : venous

A nurse is teaching a client who has a new prescription for alendronate for the treatment of osteoporosis. which of the following statements by the client indicates an understanding of the teaching?

I will sit upright after taking my medication

A nurse is reinforcing teaching with a client about the manifestations of an allergic reaction. The nurse should explain that histamine release causes which of the following reactions?

Increased mucus secretio

a nurse in the PACU is assessing a newly admitted client and observes intercostal retractions and a high pitched inspiratory sound. the nurse should identify these findings as manifestations of which of the following complications

Respiratory obstruction

A nurse is teaching 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 renal biopsy involved a tissue biopsy through needle insertion into the lower lobe of the client should maintain bed rest in a supine position with a back roll for support for 2-24 hours following the procedure to reduce the risk for bleeding. The nurse can elevate the head of the bed.)

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

Ureter

A nurse is teaching the client about the prostate-specific antigen (PSA) test. Which of the following directions should the nurse provide?

You should not ejaculate for 24 hours prior to the PSA test

deficiency in vitamin A

causes night blindness and immunodeficiency

whats a way to remember scurvy

curvy C deficiency. its a delayed wound healing of capillary fragility

A nurse is assessing a client who has right sided heart failure. Which of the following findings should the nurse expect? a) Decreased capillary refill b) Dyspnea c) Orthopnea d) Dependent edema

d) Dependent edema Blood return from the venous system to the right atrium is impaired by a weakened right heart. The subsequent systemic venous backup leads to development of the dependent edema.

A nurse is teaching a client who has a new diagnosis of primary open-angle glaucoma (POAG). What information should the nurse include in the teaching? (select all) 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 fluid

d. driving can be dangerous due to the loss of peripheral vision e. laser surgery can help reestablish the flow of aqueous fluid A IS WRONG: eye drops wont improve vision, but they can reduce intraocular pressure and prevent future vision loss. B IS WRONG: should administer eye drops on regular basis to reduce intracocular pressure C IS WRONG: presbyopia isnt related

A nurse is assessing a client who has Graves' disease. Which of the following findings should the nurse expect the client to display?

difficulty sleeping

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

deficiency in vitamin D

manifestations of rickets and osteomalacia, like bowed legs, fractures, and malformed teeth

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? Rationale: Heterografts are obtained from an animal, usually a pig. Cadaver skin pig skin Amniotic membrane beef collagen

pig skin Rationale: Heterografts are obtained from an animal, usually a pig.

deficiency in B3

produces manifestations of pellagra, like scaly rash on sun-exposed skin, confusion, paranoia, and diarrhea

an emergency room nurse is assessing a client who has a new traumatic brain injury. the nurse observes extension of the clients 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 oxygen D. initiate seizure precautions

provide oxygen 1st priority. he may need an artificial airway and mechanical ventilation because these are decerebrate positioning, which is associated with brainstem injury and can lead to brain herniation and death.

A nurse in a providers office is assessing a client who has GERD. the nurse should expect the client to report which of the following manifestations? select all that apply

regurgitation Nausea Belching Heartburn

a pt had a thoracic lobectomy and now has 2 chest tubes in place. 1 in the lower portion of the thorax and one higher on the chest wall. When a family member asks why the client has 2 chest tubes, which of the following responses should the nurse make A. two tubes were necessary due to excessive bleeding from the area of the surgery B. the tubes drain blood from 2 different lung areas C. lower tube will drain blood, higher tube will remove air D. 2nd tube will take over if blood clots block the first tube

the lower tube will drain blood, and the higher tube will remove air. A-excessive bleeding means theres a complications B-blood typically drains from the base, not the apex D-if tube becomes blocked, the nurse should report it to the surgeon and prepare to attempt to re-establish patency

teaching foot care to a diabetes pt. which info should you teach

wash feet in lukewarm water with soap every day. dont wear nylon, flip flops, or put lotion in between toes