ATI FINAL Medical Surgical

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A nurse is providing instructions about foot care for a client who has a peripheral arterial disease. The nurse should identify that which of the following statements by the client indications understanding of the teaching

"I rest in my recliner with my feet elevated for about an hour every afternoon"

a nurse is planning care a client who has dementia. Which of the following interventions should the nurse plan to include?

- Turn off the lights in the client's rom at night - Assist the client with toiling at least once every 4 hr

A nurse is teaching about measure to prevent recuring urinary tract infections with a female client. Which of the following information should the nurse include in the teaching?

- Wipe the perineal area from front to back after urinating. - Drink 3L of fluids daily - Drink low-fructose cranberry juice

A nurse is preparing to administer a unit of packed RBCs to a client who is anemic. Identify the sequence of steps the nurse should follow.

1. obtain venous access using a 19-gauge needle 2. Obtain the unit of a packed RBCs from blood bank 3. verify blood compatibility with another nurse 4. Initiate traensfuntion of the unit of packed RBCs 5. Remain with the client for the first 15 to 30 minutes

A nurse is preparing to administer lactated Ringer's via continuos IV infusion at 200 ml/hr. The IV tubing has a drop factor of 10 drops/mL. How many gtt/min should the nurse set the IV ump to administer?

33

A critical care nurse is assessing a client who has a severe head injury. In response to painful stimuli, the client does not open her eyes, displays decerebrate posturing and makes incomprehensible sounds. which of the following glasgow Coma scale scores should the nurse assign the client?

5

A nurse is admitting a client to the emergency department after a gunshot wound to the abdomen. Which of the following actions should the nurse take to help prevent the onset of acute kidney failure? a. Insert a urinary catheter b. Administer IV fluids to the client c. Prepare the client for an intravenous pyelogram d. Initate beta-blocker therapy

Administer IV fluids to the client

A nurse is planning care for a client who has full-thickness burns on the lower extremities. Which of the following interventions should the nurse include?

Apply new gloves when alternating between wound care sites.

A nurse in the post anesthesia care unit is assessing a client following an appendectomy and finds a 2 cm (3/4 in) area of blood on the postoperative dressing. which of the following actions should the nurse take?

Apply pressure

A nurse is caring for a client who has cervical cancer and a sealed radiation implant. Which of the following actions should the nurse take?

Attach a dosimeter badge to the client's gown

a nurse is providing discharge teaching to a client who is recovering from a sickle cell crisis. which of the following instructions should the nurse include?

Avoid extremely hot or cold temperatures

A nurse is preparing a client for a lumbar puncture which of the following images indicates the position the nurse should assist the client into for this procedure?

B.

A nurse is preparing to receive a client from surgery following a transverse colon resec on with colostomy placement. The nurse should expect assess the stoma at which of the following locations?

B. on top

A nurse is reviewing ECG rhythm strips for a group of clients. the nurse should identify that which of the following rhythms indicates bradycardia?

C

A nurse is providing teaching to a client who has an impaired immune system due to chemotherapy. which of the following information should the nurse include in the teaching?

Change your pet's litter box daily

A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The client reports sharp lower abdominal pain. Which of the following actions should the nurse take first?

Check the client's urine output

A nurse is preparing to administer 1 unit of packed RBCs to an adult client. Which of the following ac ons should the nurse plan to take?a. Slow the transfusion rate if the client reports itching b. Prime the IV tubing with 0.45% sodium chloride c. Complete the transfusion within 2hr d. d. Administer through a 22-gauge

Complete the infusion within 2 hr

A nurse in a provider office is caring for a client who has total vision loss and is the handler of a service dog. which of the following actions should the nurse take to show consideration for the client and the service animal?

Consult the client before approaching the dog.

A nurse is caring for a female client who is receiving total parenteral nutrition without fat emulsion. Which of the following findings should the nurse report.?

Crackles in the bilateral lung bases

A nurse is assessing a client who has a pressure ulcer. Which of the following findings should the nurse expect as an indication the wound is healing?

Dark red granulation tissue

a nurse is caring for a client who has a contusion and reports thirst. The client's urinary output was 4,000 ml over past 24 hr. the nurse should anticipate a prescription for which of the following IV medications?

Desmopressin

A nurse is caring for a client following a cardiac-catherization who has hives and urticaria following administration of IV contrast dye. Which of the following Medication should the nurse plan to administrer?

Diphenidramine

A home care nurse to use non-pharmacological pain relief measures for an adult client who has severe chronic back pain. which of the following guideline should the nurse use?

Discontinue opioids before trying non pharmacological methods of pain relief

A nurse is reviewing the laboratory reports of a client who has acute pancreatitis. Which of the following findings should the nurse expect?

Elevated blood glucose

A nurse is planing care for an older adult client who has Menier's disease. Which of the following interventions should the nurse include in the plan?

Encourage the client to change positions slowly

A nurse is teaching a client about using a metered-dose rescue inhaler. which of the following statements should the nurse include in the teaching?

Exhale fully before bringing the inhaler to your lips

A nurse is caring for a client who has hypotension, cool and clammy skin, tachycardia, and tachypnea. In which of the following positions should the nurse place the client?

Feet elevated

A nurse is planning care for a client who has a central venous access device for intermittent infusions. Which of the following actions should the nurse include in the plan of care? a. Flush the catheter using a 10-ml syringe b. Use clean technique when changing the dressing C. Cleanse the site with povidone-iodine D. Change the dressing every 24hr

Flush the catheter using a 10 ml syringe

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?

Frothy sputum

A nurse is caring for a client admitted with a skull fracture. which of the following assessment findings should be greatest concern to the nurse?

Glasgow coma scale score changes from 14 to 9

A nurse is caring for a client who is postoperative following a partial thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider?

High-pitched sound on inspiration

A nurse is reviewing the medical record of a client to identify factors for colorectal cancer. The nurse should identify which of the following findings as increasing the client's risk?

Historyof Crohn's disease

A nurse is teaching a client. about the nurse of the incentive spirometer. which of the following instructions should the nurse include in the teaching?

Hold breaths 3 to 5 seconds before exhaling

A nurse is caring for a client who is 6hr postopera ve following a thyroidectomy. The client reports tingling and numbness in the hands. The nurse should identify this as a sign of which of the following electrolyte imbalance?

Hypocalcemia

a nurse is caring for a client who is receiving epidural analgesia. Which of the following assessment finding is the nurse's priority?

Hypotension

A nurse is caring for a client who is scheduled for a mastectomy. The client tells the nurse, "I'm not sure I want to have a mastectomy." Which of the following statements should the nurse make?

I can give you additional information about the procedure

A nurse is providing discharge teaching to a client who has heart failure and instructs him to limit sodium intake to 2 g per day. Which of the following statements by the client indicates an understanding of the teaching?

I can have a frozen fruit juice bar for dessert

A nurse is assessing a client who has myasthenia gravis. Which of the following client statements should indicate to the nurse that the client needs a referral for occupational therapy?

I have a hard time with brushing my hair

A nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching.

I should expect less than 25 ml of secretions per day in the drainage devices

A nurse is reviewing medications taken at home with a client who has angina. which of the following statements by the client indicates an underestanding of the teaching?

I should lie down before taking a dose of isosorbide dinitrate

A nurse is providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following client statements indicates an understanding of the teaching?

I should lie down when I take this medication

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

I will expect my stools to be loss

A nurse is caring for a client who has a lower extremity fracture and a prescription for crutches. which of the following client statements indicates that the client is adapting to their role change?

I will need to have my partner take over shopping for groceries and cooking the meals for us

A nurse is providing discharge teaching for a client who has a new tracheostomy. Which of the following statements by the client indicates an understanding of the teaching?

I'll cut a slit in a clean gauze pad to use as a stoma dressing

A nurse is assessing an older adult client at a health fair. Which of the following statements by the client is the nurse's priority?

In the last day, I have had a severe headache and pain around my right eye.

A nurse is assessing a client who has new diagnosis of DM1. Which of the following findings indicate that the client is experiencing hypoglycemia?

Increased perspiration

A nurse is teaching a client who has Grave's disease about recognizing the manifestations of thyroid storm. Which of the following findings should the nurse include in the teaching?

Increased temperature

A nurse is caring for a client in diabetic ketoacidosis (DKA) Which of the following is the priority intervention by the nurse?

Infuse 0.9% normal saline

A nurse is caring for a client who has duodenal ulcer. which of the following actions should the nurse take? (click on the Exhibit button for additional information.

Infuse packed RBCs

A nurse is planning care for a client who has a pulmonary embolism. which of the following interventions should the nurse include?

Initiate a continuos IV heparin infusion

A nurse in the emergency department is assessing a client. which of the following actions should the nurse take first? (click on rhe "exhibit" button for additional information about the client

Initiate airborne precautions

A nurse in the emergency department is caring for a client who is in hypovolemic shock. Which of the following ac ons should the nurse take first?

Insert a large-bore IV catheter

A nurse is providing discharge teaching to an older adult client following total hip arthroplasty. Which of the following instructions should the nurse include in the teaching.

Install a raised toilet seat in your bathroom

A nurse is providing teaching for a client who has tuberculosis and a new prescription for pyrazinamide. The nurse should instruct the client to notify the provider if which of the following adverse effects occurs?

Jaundice

A nurse is caring for a client who has cervical cancer and is receiving brachytherapy. Which of the following actions should the nurse take?

Keep soiled bed linens in the client's room

A nurse is caring for a client who is receiving chemotherapy and requests information about acupuncture to relieve some of the side effects. which of the following findings should the nurse identify as a contraindication to receiving this alternative therapy?

Lymphedema

A nurse is planning care for a client following a cardiac catheterization. which of the following actions should the nurse take.

Maintain the client's affected extremity in extension

A nurse is preparing to discharge a client who has a halo device and is reviewing new prescription ons from the provider. The nurse should clarify which of the following prescriptions ons with the provider?

May operate a motor vehicle when no longer taking analgesics

A nurse is planning care for a client who is 8 hr postoperative following a coronary artery bypass grafting. which of the following assessments should the nurse plan to perform first?

Measure the client's core body temperature

A nurse is preparing to administer daily medications to a client who is undergoing a procedure at 1000 that requires IV contrast dye. which of the following routine medications to give at 0800 should the nurse withhold? a. Metformin b. Metoprolol c. Valporic acid d. Fluticasone

Metformin

A nurse is caring for a client who sustained a spinal cord injury in a diving accident. which of the following actions should the nurse take?

Monitor urine output hourly

A nurse is caring for a client who is postoperative following a complete thyroidectomy, which of the following findings is the priority for the nurse to report to the provider?

Muscle twitching

A nurse is assessing a client who has heart failure and is receiving a loop diure c. Which of the following nding indicates hypokalemia?

Muscle weakness

A nurse is caring for a client who has a history of chemotherapy-induced nausea and vomi ng. Which of the following medica ons should the nurse administer prior to chemotherapy?

Ondasteron

A nurse is caring for a client who has an arteriovenous graft . Which of the following findings indicates adequate circulation on of the graft?

Palpable thrill

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

Place a large pillow under the client's knees when resting.

A nurse in a clinic is providing preventive teaching to an older adult client during a well visit. The nurse should instruct the client that which of the following immunizations are recommended for healthy adult after age 60?

Pneumococcal polysaccharide Herpes zoster Influenza

A nurse is performing an ear irriga on for a client. Which of the following ac ons should the nurse take?

Point the type of the syringe toward the top of the ear canal

A nurse is planning care for a client who has left-side hemiplegia following a stroke. which of the following actions should the nurse include in the plan of care?

Position the client's table on the left side

A nurse is preparing to administer furosemide to a client who has acute heart failure. Which of the following laboratory results should the nurse identify as a contraindica on for receiving the medica on?

Potassium 3.2 mEq/L

A client who is ideal and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take?

Request an interpreter during the initial assessment

A nurse in a provider's office is teaching a client about the self-management of GERD. Which of the following instructions should the nurse include?

Sleep with the head of the bed elevated 6 inches

A nurse is assessing a client following extubation from a ventilator.for which of the following findings should the nurse intervene immediately?

Stridor

A nurse in a clinic receives a phone call from a client who recently started therapy with an ACE inhibitor and reports nagging dry cough. Which of the following responses by the nurse is appropriate?

Sucking on a lozenge may reduce the frequency of your cough

A nurse is completing an assessment of an older client and notes reddened areas over the bony prominences, but the client's skin is intact. which of the following interventions should the nurse include in the plan of care?

Support bony prominences with pillows

A nurse is caring for a client who is receiving total parenteral nutri on through a central line. The current bag is nearly empty, and a new bag is unavailable from the pharmacy. Which of the following actions should the nurse take?

Switch the infusion to a 10% dextrose solution

A nurse is planning care for a client who has status epilepticus. Which of the following interventions is the nurse's priority to include?

Turn the client lateral position during the seizure activity.

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

Urine specific gravity 1.001

A nurse is taking an admission history from a client who reports Raynaud's disease. Which of the following assessment findings should the nurse identify as a parenteral trigger for exacerbation of Raynaud's?

Using nicotine transdermal patch

A nurse is caring for a client who has hypervolemia. Which of the following is an expected assessment finding?

Weight gain

A nurse is caring for a client following a below the knee amputation. The client states, "my life is over". Which of the following responses should the nurse take?

Why do you think your life is over?

A nurse is caring for a client who is 2 days postoperative following a below the knee amputation and asks about the purpose of maintaining an elastic bandage around the residual limb of the extremity. Which of the following is an appropriate response by the nurse.

Why do you think your life is over?

A nurse is providing discharge teaching to a client who will be self-administering insulin at home. Which of the following informa on should the nurse include regarding needle disposal?

You can discard needles in an empty bleach bottle with a lid

A nurse is providing instructions ons to a client who has primary syphilis. Which of the following instructions ons should the nurse include in the discharge plan?

You will need to be monitor for 15 minutes after receiving each medication close

A nurse is providing discharge teaching to a client who has tuberculosis. Which of the following information should the nurse include in the teaching?

You will to return in 2 weeks to provide a sputum specimen.

A nurse is admi ng a client to a medical unit following placement of a permanent pacemaker. Which of the following ndings requires further assessment by the nurse? a.Hiccups b. Sneezing c. Presence of a sharp spike prior to the QRS complex on the ECG d. Presence of intrinsic P waves following a QRS complex on the ECG

a.Hiccups

A nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan of care? a. Place pillows under the client's knees b. Apply compression stocking socks c. Avoid use of anticoagulants b. Discourage leg exercises while in bed

b. Apply compression stocking socks

A nurse is assessing a client who has an arteriovenous (AV) gra in the le forearm. Which of the following ndings should indicate to the nurse a complica on of vascular access? a. Presence of a palpable thrill b. Dilated appearance of the AV site c. 2+ le radial pulse d. Absence of a bruit

d. Absence of a bruit

A nurse is caring for a client following a bronchoscopy. Which of the following action should the nurse take first? a. Provide the client with sips of water. b. Instruct the client to report bleeding. c. Inform the client they might experience a low-grade fever. d. Check the client's gag reflex

d. Check the client's gag reflex

A nurse is planning care for a client who has developed nephrotic syndrome. Which of the following dietary recommendations should the nurse include? a. Decrease carbohydrate intake b.increase phosphorus intake c. Increase potassium intake d. Decrease protein intake

d. Decrease protein intake

A nurse is instruc ng a client who has a new diagnosis of type 1 diabetes mellitus about the sick- day rules. Which of the following statements by the client indicates an understanding of the teaching? a. "I will consume 250grams of carbohydrates daily while I'm sick." b. "I will monitor my blood glucose every 8hours." c. "I will not take my diabetes medica ons while I am sick." d. I will check my urine for ketones if my blood glucose is greater than 240 mg/dL

d. I will check my urine for ketones if my blood glucose is greater than 240 mg/dL

A nurse is caring for an adolescent client who has an acute kidney injury. Which of the following laboratory findings should the nurse an cipate? a. BUN 8mg/dL b. Creatinine 0.4mg/dL c. Hgb 20g/dL d. Potassium 6.8

d. Potassium 6.8 mEq/L

A nurse in the emergency department is caring for a client who has a gunshot wound to the abdomen. Which of the following action should the nurse take first? a. Prepare the client for peritoneal lavage b. Check the color of the client's skin c. Administer an opioid analgesic d. Remove all of the client's clothing

d. Remove all of the client's clothing

A nurse is caring for an older adult client who has demen a. Which of the following ques ons should the nurse ask to assess the client's abstract thinking? a."Can you count backwards from 10 in intervals of 7?" b. "Can you tell me the state where you were born?" c."What do you understand about your condition?" d. What is mean by the saying "Don't beat around the bush?"

d. What is mean by the saying "Don't beat around the bush?"

A nurse is reviewing ABG results for a client who has COPD. Which of the following ndings should the nurse expect? a. HCO3-25 mEq/L b. PaO2 85mmHg c. pH 7.38 d.PaCO2 48 mm Hg

d.PaCO2 48 mm Hg

A nurse is preparing to perform ocular irrigation for a client following a chemical splash to the eye. Which of the following actions should the nurse plan to take first?

instill 0.9% sodium chloride solution into the affected eye

A nurse in the PACU is assessing a client who is post-operative following general anesthesia. Which of the following findings is the priority to address?

vomiting upon arousal


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