ATI Medsurg
A nurse is providing discharge instructions for a client who is postoperative following inner maxillary fixation with wiring. Which of the following pieces of information should the nurse include? A. Cut the wiring if emesis occurs B. Consume 3 meals daily as part of a low-protein diet C. Swab the mouth with hydrogen peroxide if wiring produces oral irritation D. Resume a soft diet in 3 to 5 days.
A Cut the wiring if emisis occurs
A nurse is preparing a client for a bronchoscopy. Which of the following actions should the nurse take? (SATA) A. Explain that the client will receive sedation and will not remember the procedure. B. Verify the client understands the purpose and nature of the procedure C. Offer the client sips of clear liquids until 1 hr before the test. D. Obtain a pre-procedural sputum specimen E. Instruct the client to keep his neck in a neutral position.
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. Rationale: For a bronchoscopy, clients typically receive premedication with a benzodiazepine of an opioid to ensure sedation and amnesia. The client will have signed a consent form, so the nurse should verify that the provider explained the procedure and that the client understands it.
A nurse is teaching a client about the manifestations of an allergic reaction. The release of histamine causes which of the following reactions? A. Increased mucus secretion B. Bronchial dilation C. Bradycardia D. Vertigo
A. Increased mucus secretion Rationale: the nurse should instruct the client that increased mucus secretion is a manifestation of histamine release. Histamine is the neurotransmitter the body produces during an allergic reaction.
During a neurological assessment, a nurse asks the client to name all of his children, their ages, and their birth dates. Which of the following types of memory is the nurse testing? A. Remote B. Sensory C. Immediate D. Recall
A. Remote Rationale: The nurse tests remote or long-term memory by asking questions such as where and when the client was born, his age, when he graduates high school, and what the names, ages, and birth date of his children are. The nurse can later verify this information with the client's family or friends.
A nurse is planning dietary teaching for a client who has diabetes mellitus. Which of the following actions should the nurse plan to take first? A. Obtain sample menus from the dietitian to give to the client B. Ask the client to identify the types of foods she prefers C. Identify the recommended range of the client's blood glucose level D. Discuss long-term complications that can result from non-adherence to the dietary plan.
B. Ask the client to identify the types of foods she prefers Rationale: The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the -previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the nurse should first ask the client about individual food preferences to provide an opportunity for the nurse to include these foods in her diet. Involving the client in the planning will promote her adherence to the dietary plan.
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? A. Temperature 37.8 degrees Celsius (100 degrees F) B. Erythema at the incision site C. WBC count 9,000/mm^3 D. Pain Reported as 6 on a scale of 0 to 10
B. Erythema at the incision site Rationale: Redness at the incision site is an initial sign of a wound infection and requires intervention by the nurse.
A nurse is caring for a client who has a brainstem injury. Which of the following physiological functions should the nurse monitor? A. Understanding speech B. Respiratory effort C. Decision-making ability D. Temperature control
B. Respiratory effort Rationale: The nurse should monitor the respiratory effort of a client who has an injury to the brainstem. The medulla in the brainstem controls the respiratory center.
A nurse is caring for a client with Addison's disease who has been admitted with muscle weakness, dehydration, and nausea and vomiting for the past 2 days. Which of the following prescribed medications should the nurse plan to administer? A. Rifampin B. Loperamide C. Hydrocortisone D. Spironolactone
C. Hydrocortisone Rationale: The nurse should identify that a client who has Addison's disease will require hydrocortisone to assist with replacing cortisol levels. A client who has Addison's has adrenal corticoid insufficiency, which is the inability of the pituitary to produce cortisol. Illness and stress can require steroids like hydrocortisone to restore hormone levels.
A nurse is monitoring a client who has syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which of the following findings should the nurse expect? A. Polyuria B. Dehydration C. Hyponatremia D. Hyperthermia
C. Hyponatremia Rationale: A client who has SIADH will have hyponatremia caused by the excessive release of antidiuretic hormone (ADH). As a result of the excess ADH, the client retains water, which causes dilution hyponatremia.
A nurse is caring for a client who has receptive aphasia. Which of the following communication problems should the nurse expect when assessing the client? A. The client cannot name simple objects or formulate sentences or phrases. B. The client has difficulty articulating correctly due to muscle weakness of the mouth and tongue. C. The client is unable to understand words or sentences she hears. D. The client speaks words that substitute for those she intends to say.
C. The client is unable to understand words or sentences she hears. Rationale: Clients who cannot understand words or sentences they hear have receptive aphasia.
A client who just learned that he has variant (Prinzmetal's) angina asks the nurse how this type of angina compares with stable angina. Which of the following replies should the nurse make? A. "Exertion often brings on pain." B. "Variant angina occurs randomly at various times." C. "Variant angina can cause changes on your electrocardiogram." D. "Reducing your cholesterol can can help you experience less pain."
C. Variant angina can cause changes on your electrocardiogram." Rationale: Variant angina causes ECG changes that reflect coronary artery spasms, which results in less oxygen supplying the myocardium.
A nurse is assessing a client who has Guilain-Barre syndrome. Which of the following findings should the nurse expect? A. Tonic-clonic seizures B. Report of a severe headache C. Weakness of the lower extremities D. Decreased level of consciousness
C. Weakness of the lower extremities Rationale: Guilain-Barre, also called acute inflammatory demyelinating polyneuropathy, is an inflammatory disorder of the peripheral nerves. Characterized by the rapid onset of ascending weakness and paralysis, starting in lower extremities and can advance to upper.
A nurse is caring for a client who underwent radioallergosorbent (RAST) testing due to seasonal allergies. The nurse should anticipate an elevation in which of the following immunoglobulin laboratory values? A. IgM B. IgA C. IgG D. IgE
D. IgE Rationale: RAST testing involves measuring the quantity of IgE in serum after exposure to specific antigens selected on a basis of the client's symptom history. An elevated IgE indicates a positive response and is common among clients who have a history of allergic manifestations, anaphylaxis, and asthma.
A nurse is preparing a client for cardiac catheterization. Which of the following pieces of information should the nurse give the client before the procedure? (SATA) A. "You'll have to lie flat for several hours after the procedure." B. "You'll receive medication to to relax you before the procedure." C. "You'll feel a cool sensation after the injection of the dye." D. "You'll have to keep your leg straight after the procedure." E. "You'll have to limit the amount of fluid you drink for the first 24 hr."
A. "You'll have to lie flat for several hours after the procedure." B. "You'll receive medication to relax you before the procedure." D. "You'll have to keep your leg straight after the procedure." Rationale: Depending on the provider's prescription, the client should remain flat or with the head of the bed elevated to no more than 30 degrees for 2 to 6 hr after the procedure. The amount of time depends on the type of closure device the provider uses. The client will receive a mild sedative for relaxation and comfort prior to the procedure. A soft knee brace can help keep the client from bending the knee after the procedure.
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 B. Wear a gown for protection from the client's infection. C. Ask the radiology staff to perform a portable chest x-ray in the client's room. D. Place an N-95 respirator on the client.
A. Have the client wear a surgical mask Rationale: The nurse should instruct the client to wear a surgical mask. The mask will protect anyone who comes into contact with the client, including the nurse.
A nurse is caring for a client who is receiving mechanical ventilation and develops acute respiratory distress. Which of the following actions should the nurse take first? A. Initiate bag-valve-mask ventilation B. Provide the client with a communication board C. Obtain a blood sample for ABG analysis D. Document the ventilator settings
A. Initiate bag-valve-mask ventilation Rationale: The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood.
A nurse is providing teaching for a client following a below-the-knee amputation. Which of the following pieces of information should the nurse include in the teaching? A. Instruct the client to lie prone while in bed B. Ensure the client sleeps on a soft mattress C. Pull up the residual limb while in bed D. Keep the residual limb exposed to air to heal
A. Instruct the client to lie prone while in bed. Rationale: The nurse should instruct the client to lie a prone position for 20 to 30 minutes every 3 to 4 hours. This prevents the client from developing contractures while in bed.
A nurse is caring for a client who has chronic phantom limb pain following an above-knee amputation. Which of the following medication prescriptions should the nurse verify with the provider? A. Meperidine B. Amitriptyline C. Gabapentin D. Propranolol
A. Meperidine Rationale: Opioids are more effective for residual limb pain rather than phantom limb pain. Additionally, meperidine is not recommended for chronic pain because long-term use can cause accumulation of a toxic metabolite.
A nurse is teaching a client who has coronary artery disease about the difference between angina pectoris and myocardial infarction (MI). which of the following manifestations should the nurse identify as indications of MI? (SATA) A. Nausea and vomiting B. Diaphoresis and dizziness C. Chest and left arm pain that subsides with rest D. Anxiety and feelings of doom E. Bounding pulse and bradypnea
A. Nausea and vomiting B. Diaphoresis and dizziness D. Anxiety and feelings of doom Rationale: Nausea, vomiting, epigastric distress, diaphoresis (sweating), dizziness, fatigue, anxiety, and feelings of doom and fear are common manifestations of MI
A nurse is providing teaching to a client who has gout and urolithiasis. The client asks how to prevent future uric acid stones. Which of the following suggestions should the nurse provide? (SATA) A. Take allopurinol as prescribed B. Exercise several times a week C. Limit intake of foods high in purine D. Decrease daily fluid intake E. Avoid citrus juices.
A. Take allopurinol as prescribed B. Exercise several times a week C. Limit intake of foods high in purine Rationale: The nurse should inform the client that allopurinol is an anti-gout medication that reduces uric acid, which helps prevent uric acid stone formation. Immobility is a risk factor for stone formation; therefore, the client should maintain a healthy lifestyle, including regular exercise. Purine increases the risk of uric acid stone formation; organ meats, poultry, fish, red wine and gravy are high in purine.
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 B. Blanching of surrounding skin C. Dimpling D. Fading of color
A. Ulceration Rationale: Ulceration, bleeding, and exudation are indications of a mole's potential malignancy. Increasing size is also a warning sign. The nurse should emphasize the importance of lifetime follow-up evaluations and the proper techniques for self-exam of the skin every month.
A nurse is caring for a client who has recovered from acute diverticulitis. The nurse should instruct the client to increase his intake of which of the following foods when the inflammation subsides? A. Cucumbers and tomatoes B. Cabbage and peaches C. Strawberries and corn D. Figs and nuts
B. Cabbage and peaches Rationale: When the acute inflammation has subsided, the client should increase his intake of foods that are high in fiber, such as wheat bran, whole-grain bread, and fresh fruits and veggies that do not contain seeds.
A nurse in an emergency department is assessing a client who has extensive burns, including on her face. Which of the following assessments should the nurse perform first? A. Estimation of burn injury B. Characteristics of the cough and sputum C. Extent of peripheral edema D. Amount of urine output
B. Characteristics of the cough and sputum Rationale: The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern.
A nurse is caring for a client who has a fractured hip and was placed in Buck's traction 4 hr ago. Which of the following actions should the nurse take? A. Inspect the client's skin underneath the boot every 12 hr B. Encourage the client to perform dorsiflexion of the affected extremity every 2 hr C. Remove the weights from the traction while repositioning the client in bed D. Loosen the ropes if the client reports muscle spasms in the affected extremity
B. Encourage the client to perform dorsiflexion of the affected extremity every 2hr Rationale: The nurse should encourage the client to perform dorsiflexion of the affected extremity every 2 hr to assess if the client is experiencing nerve damage. Weakness of dorsiflexion can indicate peroneal nerve damage. If this occurs, the nurse should notify the provider immediately.
A nurse is providing teaching to a client who has a diagnosis of hepatitis A. Which of the following statements by the client indicates an understanding of the teaching? A. "I am unable to donate blood." B. "I will need to get a booster shot of immune serum globulin every year." C. "I should stop eating raw clams." D. "I can develop this disease by getting a tattoo."
C. "I should stop eating raw clams." Rationale: Hepatitis A is transmitted via the fecal-oral route through consumption of contaminated fruits, veggies, water, milk, or uncooked shellfish. Individuals who eat raw or steamed shellfish are at are at an increased risk of acquiring hepatitis A.
A nurse is providing discharge teaching for a client who has a newly inserted permanent pacemaker. Which of the following instructions should the nurse include in the teaching? A. "Request a provider's prescription when traveling to alert airport security." B. "Stand at least 3 feet away while using a microwave." C. "Keep your cell phone 6 inches away from your pacemaker when making a call." D. "Avoid showering for the first 2 weeks following surgery."
C. "Keep your cell phone 6 inches away from your pacemaker when making a call." Rationale: The nurse should instruct the client to keep a cell phone 6 inches away from the pacemaker when making a call to avoid interfering with the function of the generator inside the client's pacemaker.
A nurse is performing medication reconciliation for a newly admitted client who has rheumatoid arthritis (RA). Which of the following medications should the nurse identify as the treatment for this condition? A. Misoprostol B. Dantrolene C. Celecoxib D. Colchicine
C. Celecoxib Rationale: Celecoxib is a type of NSAID known as cyclooxygenase-2 (COX-2) inhibitors that are used to relieve some of the manifestations caused by RA in adults. The nurse should identify that the medication is also prescribed for osteoarthritis, spondylitis, and painful menstruation.
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? A. Ecchymosis of the thigh B. Serous drainage at the pin site C. Chest petechiae D. Muscle spasms in the left leg
C. Chest petechiae Rationale: The nurse should identify chest petechiae as an indication of fat embolism syndrome. Clients who have fractures of the long bones such as the femur are at increased risk of fat emoli. Fat emboli typically occur 12 to 48 hours after the injury when fazt droplets from the marrow enter into the systemic circulation and are deposited in the lungs. The nurse should immediately notify the provider because the client could progress to acute respiratory failure.
A nurse in a clinic is providing teaching to an adolescent client who has recurrent external otitis. Which of the following instructions should the nurse include in the teaching? A. Dry the ear canal with a cotton swab after swimming B. Apply an ice pack to the ear to relieve pain C. Instill a diluted alcohol solution into the ear after swimming D. Irrigate the ear with cool tap water to clean
C. Instill diluted alcohol solution into the ear after swimming Rationale: External otitis is an inflammation of the external auditory canal often due to the retention of water in the ear from swimming. After the inflammation is gone, the client can prevent recurrence of external otitis by instilling diluted alcohol drops to decrease bacteria and dry the external ear canal.
A nurse in the emergency department is caring for a client who has bleeding esophageal varices. The nurse should anticipate a prescription for which of the following medications? A. Famotidine B. Esomeprazole C. Vasopressin D. Omeprazole
C. Vasopressin Rationale: Vasopressin constricts the splanchnic bed and decreases portal pressure. Vasopressin also constricts the distal esophageal and proximal gastric veins, which reduces inflow into the portal system and is used to treat bleeding varices.
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 interventions by the charge nurse? A. A dressing is not applied to the port site after use B. A 22-gauge non-coring needle is used to access the port. C. Blood return is noted prior to administering the medication D. A solution of 5 mL heparin 1,000 units/mL has been prepared
D. A solution of 5mL heparin 1,000 units/mL has been prepared Rationale: Implanted ports should be flushed after each use and at least once a month when not in use. This practice is sometimes referred to as "locking" or "de-accessing". It is performed to prevent the formation of blood clots in the catheter, which would disrupt the proper functioning of the catheter. The solution of 5mL heparin should be 100 units/mL; therefore, this action requires intervention by the charge nurse.
A nurse is assessing a client who has osteoarthritis. The client's medical record indicates the presence of Heberden's nodes. Which of the following findings should the nurse expect? A. Inflamed, fluid-filled sacs over the joints B. Clubbing of the fingernails C. Flexion contrature of the fingers D. Hard lumps over the joints of the fingers
D. Hard lumps over the joints of the fingers Rationale: Heberden's nodes are hard, bony lumps or nodules in the joints of the fingers.
A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following findings indicates that the nurse should suction the client's airway secretions? A. The client is unable to speak B. The client's airway secretions were last suctioned 2 hr ago. C. The client coughs and expectorates a large mucous plug. D. The nurse auscultates coarse crackles in the lung fields.
D. The nurse auscultates coarse crackles in the lung fields. Rationale: The nurse should auscultate coarse crackles or rhonchi, identify a moist cough, hear or see secreations in the tracheostomy tube, and then suction the client's airway secretion.
