ATI Med-Surg Ch. 26-50

A nurse in a clinic is caring for a client who has suspected anemia. The nurse should anticipate a prescription from the provider for which of the following tests?

Hgb

A nurse is assessing a client for Chovstek's sign. Which of the following techniques should the nurse use to perform this test?

Tap lightly on the client's cheek

A nurse is observing a newly hired nurse on the unit who is preparing to administer a blood transfusion. Which of the following actions by the newly hired nurse requires intervention by the nurse?

Verifies blood compatibility and expiration date of the blood with an assistive personnel (AP)

A nurse is admitting a client to the coronary care unit following placement of a temporary pacemaker. Which of the following nursing actions should the nurse use to promote client safety?

Wear gloves when handling pacemaker leads Verify the use of three-pronged grounding plugs Minimize client's should movements

A nurse is caring for a client who has severe peripheral arterial disease (PAD). The nurse should expect that the client will sleep most comfortably in which of the following positions?

With the affected limb hanging from the bed

A nurse is performing a physical assessment of a client who has chronic peripheral arterial disease (PAD). Which of the following is an expected finding?

Pallor on elevation of the client's limbs and rubor when his limbs are dependent

A nurse is completing the admission assessment of a client who has suspected pulmonary edema. Which of the following are expected findings?

Tachypnea Persistent cough Orthopnea

A nurse in the emergency department is assisting with the admission of a client who has a possible dissecting abdominal aortic aneurysm. Which of the following is the priority nursing intervention?

Administer IV fluids as prescribed

A nurse educator is reviewing expected findings in a client who has right-sided valvular heart disease with a group of nurses. Which of the following should be included in the discussion?

Dyspnea Client report of fatigue Peripheral edema

A nurse is providing teaching for a client who is to have a bone marrow biopsy of the iliac crest. Which of the following statements made by the client indicates a need for further teaching?

"The type of antibiotic I need to take can be determined by this test."

A nurse caring for a client who has hemophilia. The nurse should anticipate a prescription from the provider for which of the following tests?

aPTT

A nurse is orienting a newly licensed nurse on the care of a client who is receiving hemodynamic monitoring. Which of the following statements by the newly licensed nurse indicates the teaching was effective?

"A chest x-ray is needed to verify placement."

A nurse is caring for a client in a clinic who asks the nurse why her provider prescribed 1 aspirin per day. Which of the following is an appropriate response by the nurse?

"Aspirin reduces the formation of blood clots that could cause a heart attack"

A nurse is caring for a client who has a new diagnosis of hypertension and a new prescription for spironolactone 25 mg/day. Which of the following statements by the client indicates a need for further teaching?

"I should eat a lot of fruits and vegetables, especially bananas and potatoes."

A nurse is instructing a client who has angina about a new prescription for metoprolol tartrate. Which of the following statements by the client indicates understanding of the teaching?

"I will call my doctor if my pulse rate is less than 60."

A nurse is completing discharge teaching to a client who has heart failure and is encouraged to increase potassium in his diet. Which of the following statements by the client indicates understanding of the teaching?

"I will eat more baked potatoes."

A nurse is completing discharge teaching with a client who had a surgical placement of a mechanical heart valve. Which of the following statements by the client indicates understanding of the teaching?

"I will have my prothrombin time checked on a regular basis."

A nurse is completing discharge teaching with a client who has a permanent pacemaker. Which of the following statements by the client indicates a need for further teaching?

"I will have to disconnect my garage door opener."

A nurse is discussing a new diagnosis of an aneurysm with a client. The client asks the nurse to explain what causes an aneurysm to rupture. Which of the following is an appropriate response by the nurse?

"It is due to hypertension."

A nurse is caring for a client who has a deep-vein thrombosis (DVT) and has been taking unfractionated heparin for 1 week. Two days ago, the provider also prescribed warfarin. The client questions the nurse about receiving both heparin and warfarin at the same time. Which of the following is an appropriate response by the nurse?

"It takes three or four days before the effects of warfarin are achieved and the heparin can be discontinued."

A nurse is orienting a newly licensed nurse on conditions related to metabolic acidosis. Which of the following statements by the new nurse indicates the teaching has been effective?

"Metabolic acidosis can occur due to diabetic ketoacidosis."

A nurse is caring for a client who has heart failure and asks how to limit fluid intake to 2,000 mL/day. Which of the following is an appropriate response by the nurse?

"Pour the amount of fluid you drink into an empty 2 liter bottle to keep track of how much you drink."

A nurse in a clinic is instructing a client about a fecal occult blood test, which requires mailing three specimens. Which of the following statements by the client indicates understanding of the teaching?

"This is an easy way to rule out having colon cancer."

A cardiac nurse educator is reviewing the use of the fixed rate mode pacemaker with a group of newly hired nurses. Which of the following statements by a newly hired nurse indicates understanding of the review?

"This means the pacemaker fires in an asynchronous pattern."

A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome. Which of the following statements by the newly licensed nurse indicates understanding of the teaching?

"This medication is given to facilitate ventilation."

A nurse is caring for a 72-year-old client who is to undergo a percutaneous balloon vavuloplasty. The client's daughter asks the nurse to explain the expected outcome of this procedure. Which of the following is an appropriate response by the nurse?

"This will permit your mother to resume her activities of daily living."

A nurse is teaching a client the importance of remaining still following angiography. Which of the following is an appropriate statement by the nurse?

"Too much activity places you at risk for bleeding."

A nurse is providing discharge teaching to a client who had a gastrectomy for stomach cancer. Which of the following information should be included in the teaching?

"You will need a monthly injection of vitamin B12 for the rest of your life." "Using the nasal spray form of vitamin B12 on a daily basis may be an option."

A nurse is completing preoperative teaching with a client who will undergo an elective surgical procedure that will include a blood transfusion. Which of the following statements by the nurse should be included in the teaching?

"You will receive the blood you donated 4 weeks prior to the surgery."

Which of the following clients has the greatest risk of acquiring rheumatic endocarditis?

A child who has an upper respiratory streptococcal infection

A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome (ARDS)?

A client who experienced a near-drowning incident A client following coronary artery bypass graft surgery A client who has dysphagia A client who experienced a drug overdose

A nurse on a cardiac unit is caring for a group of clients. The nurse should recognize which of the following clients as being at risk for the development of a dysrhythmia?

A client who has metabolic alkalosis A client who has COPD A client who underwent stent placement in a coronary artery

A nurse is teaching a client who has heart failure about the need to limit sodium in the diet to 2,000 mg daily. Which of the following foods should be consumed in limited quantities?

Cheddar cheese, 2 oz. Hot dog Canned tuna, 3 oz. Baked ham, 3 oz.

A nurse is caring for a client who is 4 hr postoperative following coronary artery bypass grafting (CABG) surgery. He is able to inspire 200 mL with the incentive spirometer, then refuses to cough because he is tired and it hurts too much. Which of the following is an appropriate nursing intervention?

Administer IV bolus analgesic, and return in 15 min.

A nurse in the emergency department is assessing a client who was in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, hear rate 124/min, respiratory rate 38/min, temperature 38.6C (101/4F), and SaO2 92% on room air. Which of the following actions should the nurse take first?

Administer oxygen via a high-flow mask

A nurse is planning care for a client who has septic shock. Which of the following is the priority action for the nurse to take?

Administering antibiotic therapy

A nurse is admitting a client who has a suspected myocardial infarction (MI) and a history of angina. Which of the following findings will help the nurse distinguish angina from an MI?

Angina can be relieved with rest and nitroglycerin

A nurse is caring for a client who is receiving hemodynamic monitoring and has the following hemodynamic readings: PAS 34 mm Hg, PAD 21 mm Hg, PAWP 16 mm Hg, and CVP 12 mm Hg. For which of the following is the client at risk?

Heart failure Cor pulmonale Pulmonary hypertension Peripheral edema

A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following medications should the nurse anticipate administering to the client?

Heparin

A nurse is admitting a client who has complete heart block as demonstrated by ECG. The client's pulse rate is 34/min, blood pressure is 83/48 mm Hg, and he is lethargic and unable to complete sentences. Which of the following actions should the nurse perform first?

Cleanse the client's skin with soap and water

A nurse is planning caring for a client who had a surgical placement of an synthetic graft to repair an aneurysm. Which of the following interventions should the nurse include in the plan of care?

Assess pedal pulses Monitor for an increase in pain below the graft site Administer prescribed antiplatelet agents

A nurse is having difficulty arousing a client following an esophagogastroduodenoscopy (EGD). Which of the following is the priority action by the nurse?

Assess the client's airway

A nurse is caring for a client who has heart failure and reports increased shortness of breath. The nurse increases the oxygen per protocol. Which of the following actions should the nurse take first?

Assist the client into high-Fowler's position

A nurse in a cardiac unit is assisting with the admission of a client who is to undergo hemodynamic monitoring. Which of the following actions should the nurse anticipate performing?

Assist with insertion of pulmonary artery catheter.

A nurse is caring for a client following peripheral bypass graft surgery of the left lower extremity. Which of the following client findings pose an immediate concern?

Capillary refill of affected limb of 6 seconds Mottled appearance of the limb

A nurse is caring for a client and reviewing a new prescription for an afterload-reducing medication. The nurse should recognize that this medication is administered for which of the following types of shock?

Cardiogenic

A nurse is reviewing the bowel prep using polyethylene glycol with a client scheduled for a colonoscopy. Which of the following should be included in the teaching?

Check with the provider about taking current medications when consuming bowel prep.

A nurse is caring for a client who has pericarditis. Which of the following expected findings should the nurse anticipate?

Friction Rub

A nurse is caring for a client following the insertion of a temporary venous pacemaker via the femoral artery that is set as a VVI pacemaker rate of 70/min. Which of the following findings should the nurse report to the provider?

Cool and clammy foot with capillary refill of 5 seconds Twitching of intercostal muscle

A nurse is reviewing clinical manifestations of a thoracic aortic aneurysm with a newly hired nurse. Which of the following should the nurse include in the discussion?

Cough Shortness of breath Altered swallowing

A nurse is completing the admission physical assessment of a client who has a history of mitral valve insufficiency. Which of the following is an expected finding?

Crackles in lung bases

A nurse is caring for a client who has idiopathic thrombocytopenic purpura (ITP). The nurse should notify the provider and report possible small-vessel clotting when which of the following is assessed?

Cyanotic nail beds

A nurse is admitting a client who reports nausea, vomiting, and weakness. Upon assessment, the client has dry oral mucous membranes, temperature 38.5C (101.3F), pulse 92/min, respirations 24/min, skin cool with tenting present, and blood pressure 102/64 mm Hg. His urine is concentrated with a high specific gravity. Which of the following are clinical manifestations of fluid volume deficit?

Decreased skin tugor Concentrated urine Low-grade fever Tachypnea

A nurse is assessing a client who has hyperkalemia. Which of the following conditions is associated with this electrolyte imbalance?

Diabetic keloacidosis

A nurse is monitoring a client who began receiving a unit of blood 10 min ago. Which of the following should pose an immediate concern for the nurse?

Dyspnea Client report of itching Client appears flushed

A nurse is admitting an older adult client who is experiencing dyspnea, weakness, and weight gain of 2 lb, with 1+ bilateral edema of the lower extremities. Upon assessment, the client has a temperature 37.2 C (99F), pulse 96/min, respirations 26/min, oxygen saturation 94% on 3 L oxygen via nasal cannula, and blood pressure 152/96 mm Hg. Which of the following clinical manifestations are indicative of fluid volume excess?

Dyspnea Edema Hypertension Weakness

A nurse is caring for a client who has a laboratory finding of serum potassium 5.4 mEq/L. The nurse should assess for which of the following clinical manifestations?

ECG changes

A nurse is screening a client for hypertension. Which of the following actions by the client increase his risk for hypertension?

Eating popcorn at the movie theater Consuming 36 oz. of beer daily

A nurse is teaching a client who has a new prescription for clopidogrel. Which of the following should be included in the teaching?

Effects may not be apparent for several weeks Monitor for the presence of black, tarry stools

A nurse in the emergency department is caring for a client who has an allergic reaction to a bee sting. The client is experiencing wheezing and swelling of the tongue. Which of the following medications should the nurse expect to administer first?

Epinephrine

A nurse is assessing a client and suspects the client is experiencing disseminated intravascular coagulation (DIC). Which of the following physical findings should the nurse anticipate?

Epistaxis

A nurse is caring for a client who is receiving vecuronium for acute respiratory distress syndrome (ARDS). Which of the following medications should the nurse anticipate administering with this medication?

Fentanyl Midazolam

A nurse is caring for a client who experienced defibrillation. Which of the following should be included in the documentation of this procedure?

Follow-up ECG Energy settings used Skin condition under electrodes

A nurse is teaching a client who has a new prescription for ferrous sulfate. Which of the following should be included in the teaching?

Food high in vitamin C will promote absorption

A nurse is caring for a client who has a nasogastric tube attached to low intermittent suctioning. The nurse should monitor for which of the following electrolyte imbalances?

Hypernatremia

A nurse is caring for a client who is dehydrated. Which of the following clinical manifestations should the nurse assess for that is indicative of fluid volume deficit?

Hypotension

A nurse is admitting a client with a suspected occlusion of a graft of the abdominal aorta. Which of the following is an expected clinical finding?

Increased abdominal girth

A nurse is completing preprocedure teaching for a client who will undergo a sigmoidoscopy. Which of the following should be included in the teaching?

Increased flatulence can occur following the procedure NPO status should be maintained preprocedure

A nurse is assessing a client who has splinter hemorrhages in her nail beds and reports a fever. For which of the following conditions is the client at risk?

Infective endocarditis

A nurse is caring for a client following a coronary artery bypass graft (CABG). Hemodynamic monitoring has been initiated. Which of the following actions by the nurse facilitate correct monitoring readings?

Level transducer to phlebostatic axis Zero transducer to room air Observe trends in readings Compare readings to physical assessment

A nurse working on a cardiac unit is admitting a client who is to undergo a cardioversion and is reviewing the health record. Which of the following data requires that the nurse notify the provider to cancel the procedure? Mar: Ferrous Sulfate 200 mg PO 0800 and 2000, Diazepam 2 mg PO 0800 and 2000, Isosorbide 2.5 mg PO 4x a day AC and HS Vital Signs: 0800 T 99F (37.2C), BP 142/86 mm Hg, HR 88/min and irregular, Respirations 20/min History and Physical: bariatric surgery 10 years ago, dyspnea with exertion for 3 yrs., Atrial fibrillation began 3 yr. ago, Client reports taking the following medications for the past 6 weeks-iron supplement, multivitamin, antilipemic, and nitroglycerin

Medication history

A nurse is admitting a client who has been vomiting for 24 hr. Arterial blood gases are obtained. Based on the laboratory findings, which of the following conditions should the nurse expect?

Metabolic alkalosis

A nurse in an urgent care clinic is obtaining a history from a client who has type 2 diabetes mellitus and a recent diagnosis of hypertension. This is the second time in two weeks that the client experienced hypoglycemia. Which of the following data should the nurse report to the provider?

Takes metoprolol daily

A nurse is caring for an older adult client in a long-term care facility. The client has become weak and confused. He ate 40% of his breakfast and lunch. Upon assessment, the client's temperature is 38.3C (100.9F), pulse rate 92/min, respirations 20/min, and blood pressure 108/60 mm Hg. He has lost 3/4 lb and reports dizziness when assisted to the bathroom. He also has a nonproductive cough with diminished breath sounds in the right lower lobe. Which of the following actions should the nurse take?

Monitor respirations for shortness of breath.

A nurse is providing discharge teaching for a client who has a prescription for furosemide 40 mg PO daily. What time of day should the nurse encourage the client to take this medication?

Morning

A nurse is caring for a client who is admitted to the emergency department with a blood pressure of 266/147 mm Hg. The client reports a headache and states that she is seeing double. The client states that she ran out of her diltiazem 3 days ago, and she has not been able to purchase more. Which of the following nurse interventions should the nurse expect to perform first?

Obtain IV access and prepare to administer an IV antihypertensive

A nurse on a cardiac unit is caring for a client who is on telemetry. The nurse recognizes the client's heart rate is 46/min and notifies the provider. The nurse should anticipate that which of the following management strategies will be be used for this client?

Pacemaker insertion

A nurse is reviewing a new prescription to administer 0.9% sodium chloride IV at 50 mL/hr to a client who is receiving hemodynamic monitoring and has an indwelling IV catheter in the left hand. Which of the following sites can be used for administering this solution?

Peripheral saline lock Port on proximal (CVP) lumen of pulmonary artery (PA) catheter

A nurse in a clinic is caring for a client who has been on long-term NSAID therapy to treat myocarditis. Which of the following laboratory findings should be reported to the provider?

Platelets 100,000/mm3

A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following indicates that the client's clotting factors are becoming depleted?

Platelets 100,000/mm3 Fibrinogen levels 97 mg/dL

A nurse is planning care for a client who has a Hgb of 7.5 and a Hct of 21.5. Which of the following should the nurse include in the plan of care?

Provide assistance with ambulation Monitor oxygen saturation Obtain stool specimen for occult blood Schedule daily rest periods

A nurse is planning care for a client who has severe acute respiratory distress syndrome (SARS). Which of the following should be included in the plan of care for this client?

Providing supplemental oxygen Administration of bronchodilators Maintaining ventilatory support

A nurse is completing the admission assessment of a client who will undergo peripheral bypass graft surgery on the left leg. Which of the following is an expected finding?

Report of intermittent claudication in the affected leg

A nurse in the emergency department is completing an assessment of a client who is in shock. Which of the following findings should the nurse expect?

Seizure activity Respiratory rate 42/min Weak, thready pulse

A nurse is presenting a community education program on recommended lifestyle changes to prevent angina and myocardial infarction. Which of the following changes should the nurse recommend be made first?

Smoking cessation

A nurse is completing an integumentary assessment of a client who has anemia. Which of the following is an expected finding?

Spoon-shaped nails

A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse take when there is a transfusion reaction?

Stop the transfusion Send the blood bag and IV tubing to the blood bank Maintain an IV infusion with 0.9% sodium chloride

A nurse is reviewing the health record of a client who is being evaluated for possible valvular heart disease. The nurse should recognize which of the following data as risk factors for this condition?

Surgical repair of an atrial septal defect at age 2 Hypertension for 5 years Diastolic murmur present

A nurse is assessing a client who has pancreatitis. His arterial blood gases reveal metabolic acidosis. Which of the following is an expected finding?

Tachycardia Dysrhythmia Tachypnea

A nurse in a clinic receives a phone call from a client seeking information about his new prescription for erythropoietin. Which of the following information should be reviewed with the client?

The client should have his hemoglobin checked twice a week.

A nurse educator is reviewing the use of cardiopulmonary bypass during surgery for coronary artery bypass grafting with a croup of nurses. Which of the following should be included in the discussion?

The client's demand for oxygen is lowered Motion of the heart ceases Rewarming of the client takes place

A nurse is caring for a client who has laboratory findings of serum Na+ 133 mEq/L and K+ 3.4 mEq/L. Which of the following treatments can result in these laboratory findings?

Three tap water enemas

A nurse is admitting a client who has suspected rheumatic endocarditis. The nurse should anticipate a prescription from the provider for which of the following laboratory tests to assist in confirmation of this diagnosis?

Throat culture

A nurse on a cardiac unit is reviewing the laboratory findings of a client who has a diagnosis of myocardial infarction (MI) and reports that his dyspnea began 2 weeks ago. Which of the following cardiac enzymes would confirm the infarction occurred 14 days ago?

Troponin T

A nurse is caring for a client who has chronic venous insufficiency. The provider prescribed thigh-high compression stockings. The nurse should instruct the client to

apply the stockings in the morning upon awakening and before getting out of bed

A nurse should remain with a client during the first 15 min of a blood transfusion to

assess for an adverse reaction.

A nurse is caring for a client following an angioplasty that was inserted through the femoral artery. While turning the client, the nurse discovers blood underneath the client's lower back. The nurse should suspect

bleeding from the incisional site

A nurse is caring for a client admitted with confusion and lethargy. The client was found at home unresponsive with an empty bottle of aspirin lying next to her bed. Vital signs reveal a blood pressure of 104/72 mm Hg, heart rate of 116 beats/min with a regular rhythm, and a respiratory rate of 42/min and deep. Which of the following arterial blood gases findings should the nurse expect?

pH 6.98, PaO2 100 mm Hg, PaCO2 30 mm Hg, HCO3- 18 mEq/L

A nurse is caring for a client who was in a motor-vehicle accident. He is reporting chest pain and difficulty breathing. A chest x-ray reveals the client has a pneumothorax, and arterial blood gases are obtained. Which of the following findings should the nurse expect?

pH 7.06, PaO2 86 mm Hg, PaCO2 52 mm Hg, HCO3- 24 mEq/L

A student nurse is observing a cardioversion procedure and hears the team leader call out, "Stand clear." The student should recognize the purpose of this action is to alert personnel that

they cannot be in contact with equipment connected to the client