Ati med surg
A nurse is caring for a client who has a major burn injury and is experiencing third spacing. Which of the following fluid or electrolyte imbalances should the nurse expect?
Elevated Hct
A nurse is examining the ECG of a client who has hyperkalemia. Which of the following ECG changes should the nurse expect?
Elevated ST segments
A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (Ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy?:
Infection
A nurse is preparing an in-service program about the stages of acute kidney injury. Which of the following pieces of info should the nurse include about prerenal azotemia?
Interference with renal perfusion causes prerenal azotemia.
A charge nurse is observing a newly licensed nurse administer an IV medication to a client who has an implanted venous access port. Which of the following observations requires intervention by the charge nurse
✅ D. A solution of 5 mL heparin 1,000 units/mL has been prepared.
A nurse is assessing a client who has cholecystitis. Which of the following findings should the nurse expect?
A. Blumberg's sign
A nurse is teaching a female client with a new diagnosis of systemic lupus erythematosus (SLE) about factors that can trigger an exacerbation of SLE. The nurse should determine that the client requires further teaching if she identifies which of the following as an exacerbation factor
A. Exercise
A nurse is preparing a client for a bronchoscopy. Which of the following actions should the nurse take? (Select all that apply.)
A. Explain that the client will receive sedation and will not remember the procedure. B. Verify that the client understands the purpose and nature of the procedure.
A nurse is caring for a client who had a cerebrovascular accident (CVA). The client appears alert and engaged during a visit but does not respond verbally to questions. The nurse should document this as which of the following alterations?
A. Expressive aphasia
A nurse is caring for a client who has manifestations of acute tubular necrosis (ATN) following a kidney transplantation. Which of the following interventions should the nurse anticipate for this client? (Select all that apply
A. Hemodialysis B. Biopsy C. Immunosuppression
A nurse is caring for a client who is NPO and has an NG tube to suction. When the client reports nausea, which of the following actions should the nurse take?
A. Irrigate the tube with normal saline solution
A nurse is teaching a newly licensed nurse about caring for a client who is scheduled for an esophagogastric balloon tamponade tube to treat bleeding esophageal varices. Which of the following pieces of information should the nurse include in the teaching?
A. The client will be placed on mechanical ventilation prior to this procedure.
A nurse is preparing a client who is scheduled to have an arthroscopy the following day. Which of the following statements indicates that the client understands the pre-procedure teaching?
B. "The doctor will be able to see if I have signs of rheumatoid arthritis.
A nurse is providing discharge instructions to a client who is postoperative following surgical excision of a basal cell carcinoma. Which of the following findings should the nurse include as an indication of a mole's potential malignancy?
A. Ulceration
A nurse is monitoring a client for reperfusion following thrombolytic therapy to treat acute myocardial infarction (MI). Which of the following indicators should the nurse identify to confirm reperfusion?
A. Ventricular dysrhythmias
A nurse is planning care for a client who has AIDS and has developed stomatitis. Which of the following interventions should the nurse include in the plan of care?
Avoid salty foods
A nurse is assessing a client who has peripheral vascular disease and a venous ulcer on the right ankle. Which of the following findings should the nurse expect in the client's affected extremity?
B. Ankle swelling
A nurse is assessing for disseminated intravascular coagulation (DIC) in a client who has septic shock secondary to an untreated foot wound. Which of the following findings should the nurse expect? (Select all that apply.)
B. Bleeding at the venipuncture site C. Petechiae on the chest and arms E. Abdominal distension
A nurse is implementing cold therapy for a client who has an ankle sprain. Which of the following actions should the nurse take?
B. Check capillary refill before applying an ice pack to the affected area
A nurse in an emergency department is assessing a client who sustained a fall off of a roof. Which of the following findings should the nurse identify as an indication of a basilar skull fracture?
B. Clear fluid coming from the nares
A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include?
B. Cough deeply after each use
A nurse is caring for a client who has type 1 diabetes mellitus and a capillary blood glucose reading of 48 mg/dL. Which of the following findings should the nurse expect?
B. Diaphoresis
A nurse is preparing an in-service presentation about the management of myocardial infarction (MI). Death following MI is often a result of which of the following complications?
B. Dysrhythmias
A nurse is caring for a client who is taking streptomycin. Which of the following medications increases the client's risk of developing ototoxicity when taken with streptomycin?
B. Furosemide
A nurse is planning care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan of care?
B. Measure the client's abdominal girth daily
A nurse is examining the ECG of a client who has frequent premature ventricular contractions (PVCs). Which of the following QRS changes should the nurse expect to see on the client's ECG?
B. Much greater amplitude than the usual QRS complexes
A nurse is caring for a client who is experiencing autonomic dysreflexia due to a C5 spinal cord injury. After checking the client's vital signs, which of the following actions should the nurse perform next?
B. Place the client in a high-Fowler's position
A nurse is caring for a client who has a percutaneous endoscopic gastrostomy (PEG) tube and is receiving intermittent feedings. Prior to initiating the feeding, which of the following actions should the nurse take first?
B. Place the client in the semi-Fowler's position
A nurse is preparing to administer an IM injection for a client. Which of the following factors should the nurse identify as a potential contraindication to administering the medication via the IM route?
B. The client is taking an anticoagulant.
A nurse is caring for a semiconscious client who had a small-bore NG tube placed yesterday for the administration of enteral feeding. Which of the following methods should the nurse use to verify correct tube placement? (Select all that apply.)
B. Verify the initial X-ray examination C. Measure the length of the exposed tube D. Determine the pH of aspirated fluid
A nurse is teaching a client who has polycythemia vera about self-care measures. Which of the following interventions should the nurse include?
C. "Elevate your legs when sitting."
A nurse is caring for a client during the first 72 hr following a cerebrovascular accident (CVA). Which of the following actions should the nurse take?
C. Elevate the head of the bed 25° to 30° with the client in a neutral midline position
An emergency room nurse is assessing a client who has a new traumatic brain injury. The nurse observes extension of the client's arms and legs, pronation of the arms, and plantar flexion of the feet. Which of the following actions is the nurse's priority?
C. Provide supplemental oxygen
A nurse is caring for a client with Clostridium difficile who has contact-isolation precautions in place. Which of the following actions should the nurse perform?
C. Use dedicated equipment for the client.
A nurse is assessing a client who has a fractured left femur and is in skeletal traction. Which of the following findings should the nurse report to the provider?
Chest petechiae
A nurse is providing teaching to a client who is scheduled for a sigmoid colon resection with colostomy. Which of the following statements by the client indicates a need for further teaching?
D. "I'll have to consume a soft diet after surgery."
A nurse is completing an assessment for a client who has a history of unstable angina. Which of the following findings should the nurse expect?
D. Chest pain lasts for longer than 15 min.
A nurse is caring for a client following a stroke. Which of the following actions should the nurse take first?
D. Keep the client NPO
A nurse is reviewing the lab results of a lumbar puncture for a client who has manifestations of bacterial meningitis. Which of the following findings should the nurse expect?
Elevated protein
A nurse is providing teaching to a client who has a new diagnosis of myasthenia gravis (MG). Which of the following pieces of information should the nurse include?
D. Set an alarm to ensure medication dosages are taken on time
A nurse is assessing a client who sustained superficial partial-thickness and deep partial-thickness burns 72 hr ago. Which of the following findings should the nurse report to the provider?
D. Temperature of 39.1°C (102.4°F)
A client is being discharged home with oxygen therapy delivered through a nasal cannula. Which of the following instructions should the nurse provide to the client and family members?
D. Wear cotton clothing to avoid static electricity.
A nurse is teaching a client who has a new diagnosis of primary open-angle glaucoma (POAG). Which of the following pieces of information should the nurse include in the teaching? (Select all that apply.)
Driving can be dangerous due to the loss of peripheral vision. E. Laser surgery can help reestablish the flow of aqueous humor.
A nurse is caring for a client who is 2 days postoperative. Which of the following findings indicates that the client is developing an infection?
Erythema at the incision site
A nurse is assessing a client who is 12 hr postoperative following an open cholecystectomy. Which of the following findings should the nurse report to the provider?
Indwelling urinary catheter output of 25 mL/hr
A nurse is caring for a client who had a left lower lobectomy to treat lung cancer. Which of the following factors will have a significant impact on the plan of care for this client?
Lung cancer usually has metastasized before the client presents with symptoms
A nurse is teaching a client who has persistent cancer pain about the adverse effects of opioids. Which of the following statements should the nurse include in the teaching?
Physical dependence is not the same as addiction."
A nurse is assessing a client who has Kaposi's sarcoma. Which of the following findings should the nurse expect?
Reddish-purple skin lesions
A nurse is teaching a client how to perform range-of-motion exercises of the wrist. To perform adduction, which of the following instructions should the nurse include?
a. "With your palm facing down, move your wrist sideways toward your thumb."
A nurse is providing education to a client who is to undergo an EEG the next day. Which of the following info should the nurse include in the teaching?
b. "Try and stay awake most of the night prior to the procedure."
A nurse is caring for a client who is postprocedural following a lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? SATA.
b. Assist the client into a supine position d. Encourage the client to increase PO fluid intake
A nurse is monitoring the ECG of a client who has hypocalcemia. Which of the following findings should the nurse expect?
b. Prolonged QT intervals
A nurse is providing discharge teaching to a client who has a new permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching?
A. "I should check my heart rate at the same time each day."
A nurse is talking with a group of women at a community center about the current recommendations for early detection of breast cancer. The nurse should explain which of the following options?
Begin annual mammograms at age 40
A nurse is removing personal protective equipment (PPE) after performing a procedure for a client who requires isolation precautions. Which of the following items of PPE should the nurse remove first?
A. Gloves
A nurse is preparing a client who has a brain tumor for a CT scan. Which of the following factors affects the manner in which the nurse will prepare the client for the scan?
Development of hives while eating shrimp
A nurse is teaching a client who has CAD about the difference between angina pectoris and MI. Which of the following should the nurse identify as indications of MI? SATA.
N/V Diaphoresis and dizziness Anxiety and feelings of doom
A nurse is assessing a client with a closed head injury who has received mannitol for manifestations of increased intracranial pressure (ICP). Which of the following findings indicates that the medication is having a therapeutic effect?
The client's serum osmolarity is 310 mOsm/L.
A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following findings should the nurse report to the provider?
Viscous urinary output with clots
A nurse is monitoring a newly licensed nurse who is caring for a client. The client has active pulmonary tuberculosis, was placed on airborne precautions, and is scheduled for a chest X-ray. The nurse should instruct the newly licensed nurse to take which of the following actions?
✅ A. Have the client wear a surgical mask
A nurse is caring for a client who has diabetes insipidus. For which of the following findings should the nurse monitor?
✅ C. Polyuria
