ATI- PN Adult Medical Surgical Practice 2017 A

A nurse is caring for an older adult client who has a reddened area over the sacrum. Which of the following actions should the nurse take?

Minimize the time the teach of the bed is elevated

A nurse is providing discharge teaching for the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching?

Remind the client to avoid watching her feet when walking

A nurse is reinforcing discharge teaching with a client who has hearing loss. Which of the following actions should the nurse take when communicating with the client?

Rephrase client instructions when not understood

A nurse is reinforcing discharge teaching about wound care with a family member of a client who is postoperative. Which of the following should the nurse include in the teaching?

Report purulent drainage to the provider Rationale: The family member should report signs of infection, including purulent drainage.

A nurse is collecting data from a client and notices several skin lesions. Which of the following findings should the nurse report as possible melanoma?

Irregular borders

A nurse is reviewing the medical record of a client who has a prescription for morphine. Which of the following findings should the nurse report to the provider?

Urinary retention Rationale: The nurse should recognize that administering morphine to the client can cause urinary retention. Therefore, the nurse should report this finding to the provider.

A nurse is reinforcing discharge instructions with a client who is postoperative following a right hip arthroplasty. Which of the following statements should the nurse make?

"Avoid bending your hips more than 90 degrees."

A nurse is caring for a client who has terminal pancreatic cancer. The client states, "I don't think I can go on any longer." Which of the following responses should the nurse make?

"Tell me more about the way you are feeling."

A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. Which of the following statements indicates that the client is adhering to the nurse's instructions?

"I don't cross my legs anymore."

A nurse is reinforcing discharge teaching with a client who has cirrhosis. Which of the following instructions should the nurse include?

"Consume foods low in sodium."

A nurse is reinforcing teaching with a client who has mitral valve disease. Which of the following statements by the client indicates an understanding of the disease process?

"I should call my doctor if my ankles swell." Rationale: Swelling of the ankles can indicate heart failure. The client should report this findings to the provider.

A nurse is reinforcing teaching about gastroesophageal reflux disease (GERD) with a client. Which of the following statements by the client indicates an understanding of the teaching?

"I should wait at least 2 hours after eating before going to bed." Rationale: The client should wait to lie down or go to bed at least 2 hr after eating to minimize reflux.

A nurse is reinforcing teaching with an adolescent client regarding testicular self-examination. Which of the following statements by the client demonstrates an understanding of the teaching?

"I understand that pea-sized lumps are normal."

A nurse is reinforcing teaching about glycoslated hemoglobin (HbA1c) testing with a client who has diabetes mellitus. Which of the following statements indicates that the client understands the teaching?

"I will have my HgA1c checked twice per year."

A nurse is reinforcing teaching with a client who has systemic lupus erythematosus (SLE) and is to begin taking methylprednisolone orally. Which of the following statements should the nurse include in the teaching?

"Limit contact with large groups of people." Rationale: Glucocorticoids cause immunosuppression and may mask infection. The client should limit contact with sources of possible infections, such as large groups of people.

A nurse is reinforcing teaching with a client who is taking insulin glargine. Which of the following information should the nurse include in the teaching?

"This type of insulin should be given at the same time every day."

A nurse is reinforcing teaching with a client who has gonorrhea. Which of the following information should the nurse include?

"You are at risk for infertility with this infection, regardless of treatment."

A nurse is discussing health screening guidelines with an older adult client. Which of the following statements should the nurse include?

"You should have a pneumococcal immunization every 10 years."

A nurse is assisting with the care of a client who is receiving 0.9% sodium chloride by continuous IV infusion. The client reports pain and swelling at the IV site. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

- Check The IV Site - Stop the Infusion - Withdraw IV catheter - Elevate affected arm - Notify charge Nurse

A nurse is assisting with the care of a client who had a cardiac catheterization via the right femoral artery. Which of the following actions should the nurse take to prevent post procedure complications? SATA

- Position the affected extremity at a 45 degree angle - Maintain the pressure dressing - Check the client's peripheral pulses

A nurse is reinforcing teaching with a client who has asthma. Which of the following client statements indicates an understanding of the ruse of budesonide and albuterol inhalers? SATA

-"I never forget to rinse my mouth after using my budesonide inhaler." -"Between office visits, I keep a record of how many times I use my albuterol inhaler." -"I use my albuterol inhaler before I go swimming."

A nurse is preparing to administer phytonadione 7 mg subcutaneously to a client who has an INR of 4. Available is phytonadione 10 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

0.7 mL

A nurse is caring for a client who has acute pancreatitis. While providing care, the nurse observes ecchymosis around the umbilicus. The nurse should identify that this is a manifestation of which of the following?

Intra-abdominal bleedingh

A nurse is monitoring a client who is taking acarbose. Which of the following findings should the nurse identify as an adverse effect of the medication?

Abdominal cramps Rationale: Acarbose affects the gastrointestinal system. Therefore, the nurse should monitor the client for abdominal cramping, rumbling bowel sounds, and diarrhea as adverse effects of this medication.

A nurse is caring for a client and administers penicillin IM. The client begins exhibiting hives and has severe difficulty breathing. After establishing a patent airway, which of the following actions should the nurse take next?

Administer epinephrine. Rationale: The greatest risk to the client is death from anaphylaxis. Therefore, the nurse should administer epinephrine to reduce bronchospasms and laryngeal edema.

A nurse is caring for a client who had an acute ischemic stroke 1 day ago. Which of the following actions should the nurse take to reduce the risk for aspiration?

Allow for 30 min of rest before meals

A nurse is planning to implement droplet precautions for a client who has manifestations of pertussis. Which of the following interventions should the nurse include when contributing to the plan of care?

Apply a mask on the client if transport is needed

A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis. Which of the following information should the nurse include in the teaching?

Apply cold packs to the inflamed joints

A nurse is reinforcing discharge teaching to prevent dumping syndrome for a client following a partial gastrectomy for ulcers. Which of the following information should the nurse include in the teaching?

Avoid liquids at mealtimes. Rationale: The nurse should remind the client to avoid drinking liquids at mealtimes to prevent the food from emptying into the small bowel too quickly.

A nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for baclofen. Which of the following instructions should the nurse include in the teaching?

Avoid stopping this medication suddenly

A nurse is preparing to remove a client's NG tube. Which of the following intervention should the nurse take to decrease the risk of aspiration?

Pinch the NG tube

A nurse is collecting data on a client who is scheduled for a cardiac catheterization. Which of the following laboratory levels should the nurse review prior to the procedure?

BUN Rationale: BUN levels indicate kidney function. The nurse should review the lab level to determine if the client can tolerate the IV contrast dye during the procedure.

A nurse is collecting data from a client who has chronic kidney disease with hyperkalemia. Which of the following findings should the nurse expect related to hyperkalemia?

Bradycardia

A nurse is collecting data from a client who has hypothyroidism. Which os the following manifestations should the nurse anticipate?

Bradycardia

A nurse is performing an ECG on a client who is scheduled for surgery the following morning. In which of the following locations should the nurse place the V1 electrode? (You will find hot spots to select in the artwork below. Select only the hotspot that corresponds to your answer.)

C

A nurse is preparing to administer scheduled medications to a client. Which of the following prescriptions should the nurse verify with the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Ceftriaxone

A nurse is reinforcing teaching with the family of a client who has a cervical injury and has a halo vest in place. Which of the following safety precautions should the nurse include in teaching?

Change the sheepskin liner weekly

A nurse is caring for a client who has a history of breast cancer. The client asks the nurse about birth control. Which of the following methods of birth control is contraindicated for this client?

Combination oral contraceptives

A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an IV contrast agent. Which of the following laboratory findings should the nurse report to the provider prior to the procedure?

Creatinine 1.9 mg/dL Rationale: Creatinine 1.9 mg/dL is not within the expected reference range. Therefore, the nurse should report the finding to the provider before the client has a CT scan with an IV contrast agent. This finding places the client at risk for developing contrast-induced nephropathy.

A nurse is contributing to the plan of care for a client who has peripheral arterial disease (PAD) of the lower extremities. Which of the following interventions should the nurse include?

Dangle the extremities off the side of the bed. Rationale: The nurse should include in the plan of care to have the client dangle the lower extremities off the side of the bed to aid in reducing pain by increasing arterial blood flow. The client should not raise the lower extremities above the level of the heart when resting in bed because it impairs arterial blood flow.

A nurse is preparing to administer furosemide to a client who has heart failure. Which of the following findings should the nurse report before administering the medication?

Decreased potassium

A nurse is collecting data from a client who has heart failure and is taking digoxin. Which of the following outcomes from the medication should the nurse expect?

Decreased shortness of breath Rationale: The nurse should expect the client to have decreased shortness of breath. Digoxin increases the contractility of the heart, which decreases pulmonary congestion.

A nurse is caring for a client who has a prescription for phenazopyridine. Which of the following findings should the nurse identify as a therapeutic effect of the medication?

Decreases pain during urination

A nurse is assisting in the plan of care regarding bowel retraining for a client who has a cervical spinal cord injury. Which of the following interventions should the nurse plan to implement first?

Determine the client's daily elimination habits.

A nurse is caring for a client who is scheduled for surgery and is experiencing anxiety. Which of the following interventions should the nurse identity as the priority?

Determine the client's understanding of the procedure

A nurse is assisting the charge nurse with developing an in-service about caring for clients who have internal sealed radiation implants. Which of the following information should the nurse include?

Dispose of radiation implants in a lead container. Rationale: Lead impairs the emission of radiation. Therefore, the nurse should dispose of radiation implants in a lead container in accordance with facility protocol.

A nurse is caring for a client who is postoperative and has an epidural infusion. Which of the following findings should the nurse recognize as the priority?

Dyspnea

A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse identify as the priority?

Dysthymia

A nurse is caring for a client who is receiving chemotherapy. The client mentions that she has a loss of appetite because she has sores in her mouth and that food no longer tastes good. Which of the following suggestions to the client should the nurse make?

Eat several, small-portioned meals daily. Rationale: Clients who have difficulty eating because of pain or anorexia can usually tolerate small amounts of food at one time. Eating several small meals daily can increase the client's caloric intake.

A nurse is contributing to the plan of care for a client who has chronic obstructive pulmonary disease (COPD) and is dyspneic. Which of the following interventions should the nurse include in the plan?

Encourage abdominal breathing

A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking dantrolene to manage muscle spasms. Which of the following interventions should the nurse include?

Encourage the client to complete ADLs. Rationale: The nurse should encourage the client to complete ADLs and provide assistance as needed. Performing self-care increases the client's independence, strength, and level of functioning.

A nurse is caring for a client who is 24 hr postoperative following abdominal surgery and has an NG tube. Which of the following actions should the nurse plan to take to decrease the risk of postoperative complications?

Encourage the client to use an incentive spirometer every hour while awake

A nurse is contributing to the plan of care for an older adult client who is at risk for osteoporosis. Which of the following interventions should the nurse include to prevent bone loss?

Encourage weight-bearing exercises

A nurse is caring for a client who has difficulty swallowing. Which of the following actions should the nurse implement to prevent aspiration?

Give the client liquids with increased viscosity Rationale: Thickened liquids are easier for the client to swallow and can prevent aspiration.

A nurse is contributing to the plan of care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection and is on contact isolation precautions. Which of the following actions should the nurse take?

Have a designated stethoscope in the client's room

A nurse is participating in a health fair for older adult client. Which of the following immunizations should the nurse recommend for this age group?

Herpes zoster

A nurse is reviewing the laboratory results of a client who has chronic kidney failure and is receiving epoetin Alfa. The nurse should identify that which of the following laboratory values indicates the treatment is effective?

Hgb 11 g/dL

A nurse is collecting data from a 55-year-old female client who reports vaginal dryness and hot flashes. The client is interested in trying hormone replacement therapy (HRT). Which of the following should the nurse recognize as a contraindication to HRT?

History of treatment for blood clots

A nurse is preparing to auscultate the bowel sounds of a client who has a mechanical bowel obstruction in the descending colon. When listening in the left upper quadrant, the nurse should identify this sound as which of the following? (Click on the audio button to listen to the clip.)

Hyperactive bowel soudns

A nurse is reinforcing teaching about management of constipation with a client who has hypothyroidism. Which of the following should the nurse include in the teaching?

Increase intake of fiber-rich foods

A nurse is assisting in the care of a client who has manifestations of sepsis. Which of the following provider prescriptions should the nurse implement first?

Initiate oxygen at 4 L/min via nasal cannula. Rationale: When using the airway, breathing, circulation approach to client care, the first action the nurse should take is to initiate oxygen. Clients who have manifestations of sepsis are often hypoxic, tachypneic, or have a PaCO2 level less than 32 mm Hg. The nurse should provide supplemental oxygen to keep the client's oxygen saturation levels at 95% or greater, which will maximize the ability of the hemoglobin to support the oxygen needs of the body.

A nurse is contributing to the plan of care for a client who has a new prescription for nystatin suspension for oral candidiasis. Which of the following interventions should the nurse include in the plan?

Instruct the client to swish the medication in her mouth

A nurse is contributing to the plan of care for a client who os postoperative following a total know arthroplasty. The client is using a continuous passive motion (CPM) machine. Which of the following interventions should the nurse recommend for the plan of care?

Keep a sheepskin pad between the client's extremity and the CPM

A nurse is contributing to the plan of care for a client who was admitted to the neurological unit following a stroke 3 hr ago. Which of the following interventions should the nurse identify as the priority?

Keep the client in a side-laying position

A nurse is caring for a client who is in Buck's traction. Which of the following interventions should the nurse perform to reduce skin breakdown?

Keep the skin dry and free of perspiration

A nurse is reinforcing teaching with a client who is on a low-sodium diet and asks about how to improve the taste of bland food. Which of the following should the nurse recommend?

Lemon juice

A nurse is assisting a client who reports difficulty falling asleep. Which of the following activities should the nurse recommend to promote sleep?

Listen to soft music before sleeping

A nurse observes a client who is lying in bed experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

Loosen clothing around the client's neck. Rationale: The nurse should loosen clothing around the client's neck to maintain an open airway and prevent aspiration.

A nurse is caring for a client who is 3 days postoperative following a total right hip arthroplasty. Which of the following actions should the nurse take?

Maintain abduction of the client's right leg while in bed

A nurse is caring for a client who has meningococcal pneumonia. Which of the following personal protective equipment should the nurse use?

Mask

A nurse in an oncology clinic is reinforcing teaching about Mohs surgery with a client who has skin cancer. Which of the following information should the nurse include in the teaching?

Mohs surgery is a horizontal shaving of thin layers of the tumor

A nurse is assisting with the discharge planning for a client who is postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the discharge plan?

Obtain a raised toilet seat

A nurse is reinforcing teaching about dietary changes with a client who has cardiovascular disease. Which of the following images indicates the type of cooking fat the nurse should recommend the client use when preparing meals?

Olive oil

A nurse is monitoring an older adult client who has a history of an enlarged prostate and is experiencing suprapubic discomfort. Which of the following actions should the nurse take first?

Palpate the abdomen

A nurse is caring for a client who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days ago. Which of the following actions should the nurse take?

Perform pin site care daily

A nurse is caring for a client who is at risk for developing pressure ulcers. Which of the following actions should the nurse take?

Position pillows between the bone prominences

A nurse is reviewing the laboratory results of a client who has type 2 diabetes mellitus. The nurse should identify that which of the following laboratory values indicates the client is at risk for delayed wound healing?

Prealbumin 12 mg/dL Rationale: This laboratory value is below the expected reference range, indicating that the client's protein status is inadequate and that he is at risk for delayed wound healing due to malnutrition.

A nurse is caring for a client who is 1 day postoperative following a hip arthroplasty. The client is exhibiting hypotension, tachycardia, and tachypnea. The nurse should recognize that these findings indicate which of the following complications?

Pulmonary embolism Rationale: Manifestations of a pulmonary embolism include hypotension, tachycardia, and tachypnea.

A nurse is contributing to the plan of care for a client who is having difficulty eating following a stroke. Which of the following interventions should the nurse plan to implement first?

Recommend a referral for a speech language pathologist. Rationale: The greatest risk to the client following a stroke is injury from aspiration. Therefore, the first intervention the nurse should include in the plan of care is to recommend a referral for a speech language pathologist. A speech language pathologist can conduct a swallow study to determine the client's risk for aspiration, provide teaching to the client regarding swallowing techniques, and recommend the consistency of foods and liquids

A nurse is caring for a client who has bacterial meningitis. Upon monitoring the client, which of the following findings should the nurse expect?

Red macular rash Rationale: The nurse should expect to find a red macular rash, sometimes called a petechial rash, which is a manifestation of meningococcal meningitis.

Following a blood draw procedure for a fasting blood sugar (FBS) test, a client tells the nurse, "I', glad they took my blood because I'm really hungry. All I've had since midnight is water and some juice." Which of the following actions should the nurse take?

Reschedule the FBS test for early the next morning

A nurse in a long-term care facility is collecting data from a client who reports fullness in the rectum and abdominal cramping. Which of the following findings should indicate to the nurse that the client might have a fecal impaction?

Small liquid stools

A nurse enters the room of a client whose transfusion of packed RBCs was initiated 15 min ago by the RN. The client reports dyspnea and urticaria. Which of the following actions should the nurse perform first?

Stop the infusion

A nurse is caring for a client who is preoperative and is receiving an IV infusion of cefazolin. Ten minutes after beginning the infusion, the client reports intense itching. Which of the following actions should the nurse take first?

Stop the medication infusion

A nurse is reinforcing teaching about home care with a client who had a knee arthroplasty. Which of the following factors should the nurse identify as an indication that a barrier to learning might be present?

The client stops the nurse and asks for pain medication

A nurse is examining a client's IV site and notes a red line up his arm. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client's manifestations indicate which of the following complications of IV therapy?

Thrombophlebitis

A nurse is preparing to suction a client who has a tracheostomy. Which of the following actions should the nurse take first?

Ventilate with 100% oxygen. Rationale: According to evidence-based practice, the nurse should ventilate the client with 100% oxygen before suctioning to prevent hypoxemia when removing air and debris from the upper airway.

A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection in a surgical wound. Which of the following information should the nurse plan to share with visitors?

Visitors must don a gown and gloves prior to entering the client's room

A nurse is monitoring a client who recently had a cast placed on the right lower extremity for a bone fracture. Which of the following findings should the nurse recognize as abnormal?

lack of sensation between the first and second toes Rationale: Lack of sensation between the toes indicates peripheral nerve impairment and is an abnormal finding that can indicate the client has compartment syndrome. The nurse should notify the provider immediately.