ATI Med-Surg Ch. 51-75
A nurse is completing discharge teaching to a client who had a wound debridement for osteomyelitis. Which of the following information should the nurse include in the teaching?
Antibiotic therapy should continue for 3 months
A nurse who is a member of the transplant team is assessing information on a client who has end-stage kidney disease. Which of the following client indications should the nurse expect to find?
Anuria Marked azotemia Crackles in the lungs Proteinuria
A nurse is providing information about a new prescription for corticosteroid cream to a client who has mild psoriasis. Which of the following should the nurse include in the information?
Apply an occlusive dressing after application Wear gloves after application to lesions on the hands Avoid applying in skin folds
A nurse is providing information to a client who has osteoarthritis of the hip and knee. Which of the following information should the nurse include in the information?
Apply heat to joints to alleviate pain Ice inflamed joints following activity Install an elevated toilet seat Complete high-energy activities in the morning
A nurse is planning care for a client who has a small bowel instruction and a nasogastric (NG) tube in place. Which of the following nursing interventions should be included in the plan of care?
Assess bowel sounds Provide oral hygiene every 2 hr. Clamp the NG tube during ambulation
A nurse is planning care for a client who is postoperative following an arthroscopy of the knee. Which of the following is an appropriate action by the nurse?
Assess color and temperature of the extremity Elevate the extremity Administer opioid medication Assess pulse and sensation in the foot
A nurse is planning care for a client who has stage 4 chronic kidney disease. Which of the following should the nurse include in the plan of care?
Assess for jugular vein distention Provide frequent mouth rinses Auscultate for a pleural friction rub Monitor for dysrhythmias
A nurse is caring for a client who is receiving hemodialysis and develops disequilibrium syndrome. Which of the following is an appropriate action by the nurse?
Assess level of consciousness
A nurse is panning care for a client who is to have an electromyography (EMG). Which of the following should the nurse include in the plan of care?
Assess the client for bruising Apply ice to insertion sites Determine whether the client takes a muscle relaxant Instruct the client to flex muscles while the needle is inserted
A nurse is preparing educational material to present to a female client who has frequent urinary tract infections (UTIs). Which of the following findings should the nurse include?
Avoid sitting in a wet bathing suit Empty the bladder when there is an urge to void Take a tub bath daily
A nurse is reviewing the laboratory findings of a client who has an acute exacerbation of Crohn's disease. Which of the following laboratory findings is indicative of Crohn's disease?
Increased erythrocyte sedimentation rate (ESR) Increased WBC
A nurse is providing support to a client who has a recent diagnosis of endometriosis. The nurse should reinforce with the client that which of the following is a complication of endometriosis?
Infertility
A nurse is providing information about capsaicin cream to a client who reports continuous knee pain from osteoarthritis. Which of the following information should the nurse include in the discussion?
Inspect for skin irritation and cuts prior to applcation
A nurse is caring for a client who has advanced cirrhosis with worsening hepatic encephalopathy. Which of the following is an expected assessment finding?
Change in orientation Asterixis Fetor hepaticus
A nurse is planning postprocedure care for a client who received hemodialysis. Which of the following should the nurse include in the plan of care?
Check BUN and creatinine Administer medications held prior to dialysis Observe for signs of hypovolemia Assess the access site for bleeding
A nurse is providing discharge teaching to a client who is postoperative following open cholecystectomy with T-tube placement. Which of the following instructions should the nurse include in the teaching?
Clamp T-tube for 1 to 2 hr before and after meals Empty drainage bag every 8 hr
A nurse is planning discharge teaching for a client who had a total hip arthroplasty. Which of the following should the nurse include in the teaching?
Clean the incision daily with soap and water Sit in a straight-backed armchair Use a raised toilet seat
A nurse is assessing a client who has been taking prednisone following an exacerbation of inflammatory bowel disease (IBD). Which of the following assessment findings is the highest priority?
Client reports having a sore throat
A nurse is assessing laboratory values for a client who may have acute glomerulonephritis. Which of the following findings should the nurse report to the provider?
Creatinine clearance of 48 mL/min/m2
A nurse is reviewing a client's laboratory findings for urinalysis. The findings indicate the urine is positive for leukoesterase and nitrites. Which of the following is an appropriate nursing action?
Obtain a clean-catch urine specimen for culture and sensitivity
A nurse is planning postoperative care for a client who had kidney transplant surgery. Which of the following should the nurse include in the plan of care?
Obtain daily weights Assess dressings for bloody drainage Replace hourly urine output with IV fluids Monitor serum electrolytes
A nurse is preparing to administer pancrelipase to a client who has pancreatitis. Which of the following is an appropriate nursing action?
Offer a glass of water following medication administration
A client who is scheduled for kidney transplantation surgery is assessed by the nurse for risk factors of surgery. Which of the following findings increase the client's risk of surgery?
Older than 70 years of age Has a BMI of 41 Administers NPH insulin each morning Past history of lymphoma
A nurse is assessing a client who is to undergo a right knee arthroplasty. Which of the following are expected findings?
Pain when bearing weight Joint crepitus Swelling of the affected joint Limited joint motion
A nurse in a provider's office is reviewing the medical record of a client who has fibrocystic breast condition. Which of the following is an expected finding?
Palpable rubberlike lump in the upper outer quadrant
A nurse is assessing a client who has a casted compound fracture of the right forearm. Which of the following findings is an early indication of neurovascular compromise?
Paresthesia
A nurse is instructing a client how to perform Kegel exercises. Which of the following instructions should the nurse include?
Perform a set of exercises four times a day Contract the circumvaginal and/or perirectal muscles Gradually increase the contraction period to 10 seconds Follow each contraction with at least a 10-second relaxation period Perform while sitting, lying, and standing
A nurse is providing teaching on the manifestation of complications to a client who has acute glomerulonephritis. Which of the following complications should the client report to the provider?
Pitting edema
A nurse is providing care for a client who had a vertebroplasty of the thoracic spine. Which of the following is an appropriate action by the nurse?
Place the client in a supine position
A nurse is planning care for a client who has prerenal acute kidney injury following abdominal aortic aneurysm repair. The client's urinary output is 80 mL in the past 4 hr, and blood pressure is 92/58 mm Hg. Which of the following should be included in the plan of care?
Plan to administer a fluid challenge
A nurse is providing information to a client who is scheduled for a transrectal ultrasound (TRUS). Which of the following information should the nurse include?
"Sound waves will be used to create a picture of your prostate."
A nurse is preparing a client who is to receive hyaluronic acid injection for osteoarthritis. Which of the following statements by the nurse is appropriate?
"Hyaluronic acid is made from the combs of chickens."
A nurse is providing discharge instructions to a client who had a skin biopsy with sutures. Which of the following client statements indicates a need for further teaching?
"I can expect redness around the site for 3 days."
A nurse is providing teaching to a client who is scheduled for a bone scan. Which of the following statements by the nurse is appropriate?
"A radioactive substance will be injected before the procedure."
A nurse is providing teaching to a client about a new prescription for clotrimazole. Which of the following should the nurse include in the teaching?
"Apply the topical medication for up to 2 weeks."
A nurse is providing instructions for a client who is scheduled for a cervical biopsy. Which of the following should the nurse include in the instructions?
"Avoid heavy lifting for approximately 2 weeks after the procedure." "Avoid the use of tampons for 2 weeks after the procedure."
A nurse is preparing to discharge a client who has had an anterior and posterior colporrhaphy. Which of the following instructions should the nurse provide?
"Do not engage in intercourse for at least 6 weeks."
A client is admitted to the gynecology unit for an anterior colporrhaphy. Which of the following client statements is consistent with the physiological alteration that necessitates this type of surgery?
"I have had frequent urinary tract infections."
A nurse is completing nutrition teaching for a client who has pancreatitis. Which of the following statements by the client requires further teaching?
"I plan to drink regular cola."
A nurse is teaching a client how to manage an external fixation device upon discharge. Which of the following statements by the client indicates an understanding of safe management?
"I will clean the pins twice a day." "I will use a separate cotton swab for each pin." "I will report loosening of the pins to my doctor."
A nurse in a clinic is teaching a client who has ulcerative colitis. Which of the following statements by the client indicates understanding of the teaching?
"I will plan to limit fiber in my diet."
A nurse is completing preoperative teaching for a client who is ton undergo an arthroscopy to repair injury to a shoulder. Which of the following statements by the nurse is appropriate?
"Inspect your incision daily for signs of infection." "Perform isometric exercises as directed."
A nurse is providing information to a client who has chronic rejection of a transplanted kidney. Which of the following statements should the nurse include?
"Monitoring electrolytes frequently determines kidney status." "Scheduled kidney biopsies determine kidney status." "Restarting dialysis depends on marked azotemia." "Plan to have the immunosuppressive medication increased."
A nurse in a provider's office is providing information to a client who has dysfunctional uterine bleeding (DUB). Which of the following statements by the client indicate understanding of the information?
"My heavy bleeding may be due to a hormonal imbalance." "My doctor may perform a D&C to find out what's causing my abnormal bleeding."
A nurse is reinforcing teaching for a client who has a prescription for sulfasalazine. Which of the following should the nurse include in the teaching?
"Notify the provider if you experience a sore throat."
A nurse is completing teaching for a client who is scheduled for extracorporeal shock wave lithotripsy (ESWL). Which of the following statements made by the client indicates understanding of the teaching?
"Straining my urine following the procedure is important."
A nurse is presenting information to a client who has a new diagnosis of chronic glomerulonephritis. Which of the following nursing statements is appropriate?
"The cause of the disease is not known."
A nurse is providing teaching to a client who is to have an x-ray of the kidneys, ureters, and bladder (KUB). Which of the following statements should the nurse include in the teaching?
"The procedure determines whether a kidney stone is present."
A school nurse is providing an education session about menstruation with a group of adolescent female students. Which of the following statements should the nurse include?
"The range for a typical menstrual cycle is between 21 and 42 days." "Ovulation typically occurs around the 14th day of the menstrual cycle." "It is not unusual for a menstrual period to last as long as 7 days."
A nurse is preparing a client for her first Papanicolaou (Pap) test. Which of the following statements is appropriate for the nurse to make?
"You may experience some bleeding after the procedure."
A nurse is instructing a client who is scheduled for a transurethral resection of the prostate (TURP) about his postoperative care. Which of the following information should the nurse include in the teaching?
"You may have a continuous sensation of needing to void even though you have a catheter."
A nurse is completing preoperative teaching for a client who will undergo a laparoscopic cholecystectomy. Which of the following should be included in the teaching?
"You may have shoulder pain after surgery."
A nurse is performing health screenings of clients at a health fair. Which of the following clients are at risk for osteoporosis?
A 40-year-old client who takes prednisone for asthma A 45-year-old client who takes phenytoin for seizures A 65-year-old client who has a sedentary lifestyle A 70-year-old client who has smoked for 50 years
A nurse on a medical unit is caring for several clients. Which of the following clients are at risk for developing pyelonephritis?
A client who is 32 weeks of gestation A client who has kidney calculi A client who has a neurogenic bladder A client who has diabetes mellitus
A client who had an above-the-knee amputation reports having sharp, stabbing type of phantom pain. Which of the following is an appropriate action by the nurse?
Administer an antieplileptic medication
A nurse is caring for a client who has a left renal calculus and an indwelling urinary catheter. Which of the following assessment findings requires immediate intervention by the nurse?
Absent urine output for 2 hr
A nurse is teaching a client who has a history of psoriasis about photochemotherapy and ultravoilet light (PUVA) treatments. Which of the following should the nurse include in the teaching?
Administer a psoralen medication before the treatment
A nurse is caring for a client who has a urinary tract infection. The client reports pain and a burning sensation upon urination, and cloudy urine with an odor. Which of the following is the priority intervention by the nurse?
Administer an antibiotic
A nurse is instructing a client on home care after a culture for a bacterial infection and cellulitis. Which of the following information should the nurse include in the teaching?
Bathe with antibacterial soap Apply warm compresses to the affected area Allow lesions to dry before applying topical medication
A client who is menopausal asks the nurse about use of herbal therapy to treat hot flashes. Which of the following herbal supplements should the nurse recommend?
Black cohosh
A nurse is completing discharge instructions with a client who has spontaneously passed a calcium oxalate stone. Which of the following foods should the nurse instruct the client to avoid?
Black tea Spinach
A nurse is assessing a client who has prerenal acute kidney injury (AKI). Which of the following should the nurse include in the assessment?
Blood pressure Urine output Serum creatinine Serum electrolytes
A nurse is reviewing the health record of a client who is to undergo total joint arthroplasty. The nurse should recognize which of the following findings as a contraindication to this procedure?
Bronchitis 2 weeks ago
A nurse is reviewing nutrition teaching for a client who has cholecystitis. Which of the following food choices can trigger cholecystitis?
Brownie with nuts
A nurse in the emergency department is planning care for a client who has a right hip fracture. Which of the following immobilization devices should the nurse anticipate in the plan of care?
Buck's traction
A nurse is providing instructions to a client before a mammogram. Which of the following should the nurse instruct the client to avoid prior to the procedure?
Deodorant
A nurse is completing the admission assessment of a client who has a kidney stone. Which of the following is an expected finding?
Diaphoresis
A nurse in a clinic is reviewing the laboratory reports of a client who has suspected cholelithiasis. Which of the following is an expected finding?
Direct bilirubin 2.1 mg/dL
A nurse is caring for a client who has cirrhosis. Which of the following medications can the nurse expect to administer to this client?
Diuretic Beta-blocking agent Lactulose
A nurse is completing discharge teaching to a client who has irritable bowel syndrome (IBS). Which of the following should be included in the teaching?
Drink at least 2 L of fluids each day
A nurse is completing discharge teaching to a client who has Crohn's disease. Which of the following should be included in the teaching?
Drink canned protein supplements
A nurse is caring for a client who has a small bowel obstruction from adhesions. Which of the following findings are consistent with this diagnosis?
Emesis greater than 500 mL with a fecal odor Report of spasmodic abdominal pain Pain relieve with vomiting
A nurse is completing the admission assessment of a client who has acute pancreatitis. Which of the following findings is the priority to be reported to the provider?
Hand spasms present when blood pressure is checked
A nurse is presenting information to clients at a health fair on measures to reduce the risk of amputation. Which of the following information should the nurse provide?
Encourage clients who smoke to consider smoking cessation programs Encourage clients who have diabetes mellitus to maintain blood glucose within the reference range Instruct clients to unplug electrical equipment when performing repairs Encourage clients who have vascular disease to maintain good foot care
A nurse is planning care for a client who has chronic pyelonephritis. Which of the following are appropriate actions by the nurse?
Encourage daily fluid intake of 3 L Palpate the costovertebral angle Monitor urinary output Administer anti-infective medication
A nurse is caring fro a client following a below-the-elbow amputation. Which of the following are appropriate actions by the nurse?
Encourage dependent positioning of the residual limb Inspect for presence and amount of drainage Implement shrinkage intervention of the residual limb Assess for feelings of body image changes
A nurse is completing a preoperative teaching plan for a client who is to have a total hip arthroplasty. Which of the following should the nurse include in the teaching plan?
Encouraging complete autologous blood donation Using an abductor pillow when turning Performing isometric exercises
A nurse is completing an admission assessment of a client who has pancreatitis. Which of the following is an expected finding?
Epigastric pain radiating to left shoulder
A nurse is educating a female client on the use of calcipotriene topical medication for the treatment of psoriasis. Which of the following information should the nurse include?
Expect a stinging sensation upon application Apply to the scalp Obtain a pregnancy test Limit application to skin folds
A nurse is assessing a client who has a diagnosis of acute glomerulonephritis. Which of the following is an expected finding?
Fever Peripheral edema Dyspnea Proteinuria
A nurse is reviewing the medical record of a client who has premenstrual syndrome (PMS). Which of the following medications are used to treat premenstrual syndrome?
Fluoxetine Spironolactone Ethinyl estradial/drospirenone
A nurse in a provider's office is obtaining a history from a client who is being evaluated for benign prostatic hyperplasia (BPH). Which of the following findings are indicative of this condition?
Frequent urinary tract infections Hematuria Urinary incontinence
A nurse is caring for a client who has stage 4 chronic kidney disease. Which of the following is an expected laboratory finding?
Glomerular filtration rate (GFR) 20 mL/min
A nurse is monitoring a client who is receiving plasmapheresis. Which of the following should indicate to the nurse that the client is experiencing side effects from the procedure?
Heart rate 140/min Vertigo Muscle cramps Blood pressure 90/56 mm Hg
A nurse is assessing a client who has osteoarthritis of the knees and fingers. Which of the following clinical manifestations should the nurse expect to find?
Heberden's nodes Enlarged joint size Limp when walking
A nurse is providing teaching to a client who has chronic kidney disease and is to start hemodialysis. Which of the following information should the nurse include in the teaching?
Hemodialysis returns a balance to serum electrolytes
A nurse is monitoring for postoperative complications in a client who had a kidney biopsy. Which of the following complications causes the most immediate risk to the client?
Hemorrhage
A nurse is caring for a client who has type 2 diabetes mellitus and is to undergo excretory urography. Which of the following are appropriate nursing actions prior to this procedure?
Identify client allergy to seafood. Hold metformin for 24 hr. Administer an enema. Assess client for history of asthma.
A nurse is providing discharge instructions to a client who is postoperative from a TURP. Which of the following instructions should the nurse include?
If urine appears bloody, stop activity and rest Avoid drinking caffeinated beverages Take a stool softener once a day
A nurse is reviewing the health record of a client who has pancreatitis. The physical exam report by the provider indicates the presence of Cullen's sign. Which of the following is an appropriate action by the nurse to identify this finding?
Inspect the skin around the umbilicus
A nurse is completing an assessment of a client who had an external fixation device applied 2 hr ago for a fracture of the left tibia and fibula. Which of the following findings indicate compartment syndrome?
Intense pain when the left foot is passively moved Hard, swollen muscle in the left leg Burning and tingling of the distal left foot Minimal pain relief following a second dose of opioid medication
A nurse is reviewing discharge instructions with a client who had spontaneous passage of a calcium phosphate kidney stone. Which of the following should be included in the teaching?
Limit intake of food high in animal protein Reduce sodium intake Report burning with urination to the provider Increase fluid intake to 3 L/day
A nurse is teaching a client who has hepatitis B about home care. Which of the following should the nurse include in the teaching?
Limit physical activity Avoid alcohol Eat small frequent meals
A nurse is admitting an older adult client who has suspected osteoporosis. Which of the following is an expected clinical finding?
Loss in height of 2 in (5.1 cm) Body mass index (BMI) of 21 Kyphotic curve at upper thoracic spine History of lactose intolerance
A nurse is admitting a client to the orthopedic unit following a total knee arthroplasty. Which of the following actions by the nurse are appropriate?
Maintain continuous passive motion device Palpate dorsopedal pulses Elevate heels off bed
A nurse is providing teaching to a client who has a prescription for methotrexate for severe psoriasis. Which of the following information should the nurse include?
Monitor for evidence of infection
A nurse administered captopril to a client during renography. Which of the following is an appropriate action by the nurse?
Monitor for orthostatic hypotension.
A nurse is planning care for a client who is having peritoneal dialysis. Which of the following are appropriate nursing actions?
Monitor serum glucose levels Report cloud dialysate return Assess for shortness of breath Check the access site dressing for wetness
A nurse is preparing a plan of care to prevent a client from developing flexion contractions following a below-the-knee amputation 24 hr ago. Which of the following should the nurse include in the plan of care?
Position the client prone several times each day
A nurse is reviewing the laboratory findings for urinalysis (UA) of a client who reports urgency and nocturia. Which of the following findings should the nurse report to the provider?
Positive leukocyte esterase
A nurse is caring for a client who has a new diagnosis of hepatitis C. Which of the following is an expected laboratory finding?
Presence of enzyme immunoassay (EIA)
An older adult client is having an annual physical exam at a provider's office. Which of the following client findings indicates additional follow-up is needed in regard to the prostate gland?
Prostate-specific antigen (PSA) is 7.1 ng/mL The client reports a weak urine stream
A nurse on a medical-surgical unit is admitting a client who has hepatitis B with ascites. Which of the following actions should the nurse include in the plan of care?
Provide a high-calorie, high carbohydrate diet
A nurse is planning care for a client who has postrenal acute kidney injury due to metastatic cancer. The client has a serum creatinine of 5 mg/dL. Which of the following are appropriate actions by the nurse?
Provide a high-protein diet Assess the urine for blood Monitor for intermittent anuria
A nurse in a clinic is preparing to obtain a skin specimen from a client who has a suspected herpes infection. Which of the following actions should the nurse take?
Puncture the crusted area with a sterile needle Place cotton-tipped applicator in culturette tube Place culturette tube in ice
A nurse is planning discharge teaching on home safety for an older adult client who has osteoporosis. Which of the following information should the nurse include in the teaching?
Remove throw rugs in walkways Use prescribed assistive devices Remove clutter from the environment Maintain lighting of doorway areas
A nurse is preparing to initiate hemodialysis for a client who has acute kidney injury and has been hospitalized. Which of the following are appropriate nursing actions?
Review the client's current medication history Assess the client's arteriovenous fistula for a bruit Obtain the client's weight Check the client's serum electrolytes
A nurse is assessing an older adult client who has arteriosclerosis and is scheduled for a possible right lower extremity amputation. Which of the following are expected findings in the affected extremity?
Skin cool to touch from mid-calf to the toes Lower leg appears dusky when client is sitting Lack of hair on lower leg Blackened areas on several toes
A nurse is teaching diet recommendations to a client who had a kidney transplant and is taking cyclosporine. Which of the following recommendations should the nurse include in the teaching?
Take a magnesium supplement
A nurse is caring for a client who has a new diagnosis of benign prostatic hyperplasia (BPH). The nurse should anticipate a prescription for which of the following medications?
Tamsulosin
A nurse is a clinic is reviewing the facility's testing process and procedures for human immune deficiency virus (HIV) with a new employee. Which of the following information should the nurse include in the review?
The Western blot assay is used to confirm the diagnosis of HIV.
A nurse is caring for an older adult client in an extended care facility. Which of the following indicates the client has a stool impaction causing a large intestine obstruction?
The client is having small, frequent liquid stools
A nurse is educating clients at a health fair about dual x-ray absorptiometry (DXA) scans. Which of the following should the nurse include in the teaching?
The hip and spine are the usual areas to be scanned Bone pain may indicate a need for a scan At age 40 years, a baseline scan is recommended
A nurse is providing educational information on glucosamine to a group of clients at a health fair. Which of the following should the nurse include in the teaching?
The medication aids in the rebuilding of cartilage
A nurse is reviewing a new prescription for ursodiol with a client who has cholelithiasis. Which of the following should be included in the teaching?
This medication dissolves gall stones
A nurse in a provider's office is reviewing a client's laboratory results. The client's rapid plasma regain (RPR) is positive. Which of the following tests confirm the diagnosis of syphilis?
Treponema pallidum particle agglutination assay
A nurse is caring for a client who has a suspected viral skin lesion. Which of the following laboratory findings should the nurse anticipate reviewing to confirm this diagnosis?
Tzanck smear report
A nurse is completing an admission assessment of a client who has a small bowel obstruction. Which of the following findings should the nurse report to the provider?
Urine specific gravity 1.040 Hematocrit 60% Serum potassium 3.0 mEq/L
A nurse is assessing a client who has seborrheic keratosis on the forehead and nose. Which of the following manifestations should the nurse expect to find?
Waxy appearance of the lesions Black, rough lesions Wartlike surface of the lesions
A nurse is providing dietary teaching about calcium-rich foods to a client who has osteoporosis. Which of the following foods should the nurse include in the instructions?
White beans
