ATI Adult med surg A

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

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

avoid liquids at mealtimes

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 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 career for a client who has multiple sclerosis and is taking dantrolene to manage muscle spams. Which of the following interventions should the nurse include?

encourage the client to complete ADLs

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

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

herpes zoster

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 balances suspension skeletal traction 4 days ago. Which of the following actions should the nurse take?

perform pin site. care daily

A nurse is preparing to remove a clients NG tube. Which of the following interventions should the nurse take to decrease the risk for aspiration?

pinch the NG tube

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 bony prominences

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

prealbumin 12 mg/dl

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

pulmonary embolism

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 for a referral for a speech language pathologist

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

red macular rash

A nurse is preparing to administer phytonadione 7 mg subq to a client who has an INR of 4. Available is phytonadione 10 mg/ml. How many mL should the nurse administer?

0.7 mL

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

BUN

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?

C (fourth intercostal space to the right of the sternum)

A nurse is assisting with the care of a client who is receiving 0.9% 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?

Check IV site, stop the infusion, remove the IV catheter, elevate the affected extremity

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

HGB 11 g/dl

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

Have a. designated stethoscope in the clients room

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 clients adhering to the nurses instructions?

I do not cross my legs anymore

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

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

I should call my doctor if my ankle swell

A nurse is reinforcing teaching about 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

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 testicular cancer is painless

A nurse is reinforcing teaching about glycosylated hemoglobin testing with a client who has diabetes mellitus. Which of the following indicates the clients understands the teaching?

I will have my HbA1c checked twice a year

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

abdominal cramps

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

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

allow 30 min 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 instructions with a client who is postoperative following a right hip athroplasty. Which of the following statements should the nurse make?

avoid bending your hoops more than 90 degrees

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

bradycardia

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

bradycardia

A nurse is preparing to administer scheduled medications to a client. Which of the following prescriptions should the nurse verify with the provider?

ceftriaxone

A nurse is reinforcing teaching with the family of a client who has a cerevical injury and has a halo vest in place. Which of the following safety precautions should the nurse include in the 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 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 reviewing the lab results of a client who is scheduled for a CT scan with an IV contrast agent. Which of the following lab findings should the nurse report to the provider prior to the procedure?

creatinine 1.9 mg/dl

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

dangle the extremities off the side of the bed

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

A nurse is caring for a client who has a prescription for phenazopyrdrine. Which of the following findings should the nurse identity 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 cervial spinal cord injury. Which of the following interventions should the nurse plan to implement first?

determine the clients 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 indentify as the priority?

determine the clients 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 and implants in a lead container

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?

dysrhythmia

A nurse is caring for a client who is receiving chemo. The client mentions that she has a loss of appetite because she has sores in here 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

A nurse is collecting data from a 55 yr old female client who reports vaginal dryness and hot flashes. The client 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 ausculate 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?

hyperactive bowel sounds

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

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 thee nurse include in the plan?

instruct the client to swish the medication in her mouth

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

intra abdominal bleeding

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

irregular borders

A nurse is contributing to the plan of care for a client who is postoperative following a total knee athroplasty. 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 clients extremity and the CPM

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

keep the client in a side lying position

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

keep the skin and free of perspiration

A nurse is monitoring a client who recently has a cast places 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

A nurse is reinforcing teaching with a c 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 reinforcing teaching with a client who has systemic lupus erthematosus (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

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 clients neck

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

maintain abduction of the clients tight leg while in bed

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

mask

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

minimize the time the head of the bed is elevated

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

monitor the insertion site for bleeding, maintain the pressure dressing, check the clients peripheral pulses

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

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 reinforcing teaching with a client who has heat failure and a new prescription for hydrochlorothiazide. Which of the following findings should the nurse instruct the client to report to there provider?

onset of nausea

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

reschedule the FBS for early the next morning

A nurse in a long term career 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 is caring for a client who is preoperative and is receiving an IV infusion of cefazolin. Teen 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 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 transfusion

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

tell me more about the way you are feeling

A nurse is reinforcing teaching about home care with a client who had a knee athroplasty. 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 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 sane time everyday

A nurse is examining a clients 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 clients manifestations indicate which of the following complications of IV therapy?

thrombophlebitis

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

urinary retention

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

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

visitors must don a gown and gloves prior to entering the clients room

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 injection regardless of treatment

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

you should have a pneumococcal immunization every 10 years