MS ATI 3.0

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. Bleeding at the venipuncture site C. Petechiae on the chest and arms E. Abdominal distension

A nurse is providing teaching to a client who has dumping syndrome following gastric bypass surgery 4 days ago. Which of the following recommendations should the nurse include in the teaching? A. Avoid foods containing protein B. Drink liquids during each meal C. Eat foods that contain simple sugars D. Maintain a supine position after meals

D. Maintain a supine position after meals

A nurse is caring for a client who is postoperative following vein ligation and stripping for varicose veins. Which of the following actions should the nurse take? Encourage ambulation for 15 min every hours while awake for the first 24hr Tell the client to sit with legs dependent after ambulating Position the client supine with his legs elevated when in bed Instruct client to wear knee-length socks for 2 weeks after surgery

Position the client supine with his legs elevated when in bed.

A nurse is teaching a client who has pernicious anemia. The nurse should encourage the client to increase consumption of which of the following foods? (a) Eggs (b) Squash (c) Kale (d) Tofu

(a) EggsThe nurse should encourage the client to increase consumption of foods rich in Vitamin B12, such as dairy products, animal protein, poultry, shellfish, and eggs.

The nurse is reviewing the laboratory results from a lumbar puncture performed in a client with s/s of bacteria meningitis. Which laboratory findings are expected? 1.Increased glucose 2.Elevated protein 3.Increased RBCs 4.Presence of D-dimer

2.Elevated protein

A nurse is reinforcing preoperative teaching with a client who has lung cancer and will undergo a pneumonectomy. Which of the following pieces of information should the nurse include? SATA A. You will have a chest tube in place after surgery. B. You ill have to remain in bed for 2 days after surgery C. We'll help you turn, cough, and breath deeply frequently after surgery. D. We'll give you oxygen to support your breathing if you need it. E. You should expect pain for the first few days after surgery

A, C, D You will have a chest tube in place after surgery.We'll help you turn, cough, and breath deeply frequently after surgery. We'll give you oxygen to support your breathing if you need it.

A nurse is caring for a client who has moderate Alzheimer's disease. Which of the following actions should the nurse take? A. Add gestures when speaking with the client B. Ask open-ended questions C. Limit visitors to 3 at a time D. Use different words if the client does not understand a statement

A. Add gestures when speaking with the client

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? A. Encourage her to eat foods high in carbs B. Have her perform moderate exercise to restore her strength more quickly C. During the illness, she may take Tylenol (acetaminophen) for fever or discomfort D. The provider will prescribe medication to help her liver heal faster.

A. Clients diet should be high in carbs and calories, with only moderate amounts of protein, and fat, especially if nausea is present.

A nurse is assessing a client who has deep-vein thrombosis in her left calf. Which of the following manifestations should the nurse expect to find? (Select all that apply.) A. Hardening along the blood vessel B. Absence of a peripheral pulse C. Tenderness in the calf D. Cool skin on the leg E. Increased leg circumference

A. Hardening along the blood vessel C. Tenderness in the calf E. Increased leg circumference

A nurse on a medical-surgical unit is assessing a client who recently transferred from the ICU following endotracheal extubation. Which of the following findings should the nurse identify as a possible manifestation of tracheal stenosis and report to the provider? A. Increased coughing B. Diaphragmatic breathing C. Hemoptysis D. Kussmaul respirations

A. Increased coughing

A nurse is providing teaching for a client following a below-knee amputation. Which of the following should the nurse include in the teaching? A. Instruct the client to lie prone while in bed. B. Ensure the client sleeps on the soft mattress. C. Pull up the residual limbs while in bed. D. Keep the residual limb expose to air to heal

A. Instruct the client to lie prone while in bed.

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 right foot. Which of the following statements should the nurse make? A. This type of pain usually decreases over time as the limb becomes less sensitive. B. Try to look at the surgical wound as a reminder the limb is gone C. Use cold compress to decrease the pain sensation D. Grief over the lost limb can cause denial the limb is really gone

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

A nurse in an emergency department is assessing a client who has extensive burns, including on her face. Which of the following assessments should the nurse perform first? A. Estimation of burn injury B. Characteristics of the cough and sputum C. Extent of peripheral edema D. Amount of urine output

B. Characteristics of the cough and sputum

A nurse is planning care for a client who has thrombocytopenia. Which of the following interventions should the nurse includg 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

A nurse is reviewing the medical record of a client who has a prescription for probenecid to treat gout. The nurse should identify that which of the following medications can interact with probenecid? A. Colchicine B. Naproxen C. Aspirin D. Prednisone

C. Aspirin

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

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."

C. 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.

A nurse names 3 objects for the client to remember, asks the client to repeat them, and tells the client 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? Remote Sensory Immediate Recall

Immediate

A nurse is assessing a client who has an exacerbation of herpes zoster. Which of the following manifestations of the client's skin should the nurse expect? a. Confluent, honey-colored, crusted lesions b. Large, tender nodules located on a hair folliclec. c. Unilateral, localized, nodular skin lesions d. A fluid-filled vesicular rash in the genital region

c. Unilateral, localized, nodular skin lesions. Rationale - Herpes zoster, or shingles, results from the reactivation of a dormant varicella virus, It is the acute, unilateral inflammation of the dorsal root ganglion. The infection typically develops in adults and produces localized vesicular lesions confined to a dermatome. It produces unilateral, localized, nodular skin lesions.

A nurse in a clinic is providing teaching to an adolescent client who has recurrent external otitis. What instructions should the nurse include in the teaching? a. dry the ear canal with a cotton swab after swimming b. apply an ice pack to the ear to relieve pain c. instill a diluted alcohol solution into the ear after swimming d. irrigate the ear with cool tap water to clean

c. instill a diluted alcohol solution into the ear after swimming