ATI MedSurg

A nurse in an urgent care clinic is collecting data from a client who reports exposure to anthrax. Which of the following findings is an indication of the prodromal stage of inhalation anthrax? A. Dry cough B. Rhinitis C. Sore throat D. Swollen lymph nodes

A dry cough is a clinical manifestation of the prodromal stage of inhalation anthrax. During this stage, it is difficult to distinguish the condition from influenza or pneumonia because there is no sore throat or rhinitis.

A nurse is caring for a client who has acute diverticulitis. While the client has active inflammation, the nurse should instruct the client to include which of the following foods in her diet? A. White bread and plain yogurt. B. Shredded wheat cereal and bluberries C. Broccolo and kidney beans D. Oatmeal and fresh pears.

A. Because of the acute inflammation of diverticulitis, the client should maintain a diet very low in fiber. The client can consume low-fiber foods like white bread, low fat milk, yogurt with active cultures, poached eggs, and canned soft fruit.

A nurse is caring for a client who has 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? A. Flush the tube with water. B. Place the client in the semi-Fowler's position C. Cleanse the skin around the tube site. D. Aspirate the tube for residual contents.

B. A client is receiving PEG tube feedings should be positioned with the head of the bed elevated at least 30 degrees during and after feedings to decrease the risk of aspiration. Therefore, this is the priority action by the nurse.

A nurse is caring for a client who is in the oliguric-anuric stage of acute kidney injury. The client reports diarrhea, a dull headache, palpitations, and muscle tingling and weakness. Which of the following actions should the nurse take first? A. Administer an analgesic to the client B. Check the client's electrolyte values C. Measure the client's weight. D. Restrict the client's protein intake

B. The nurse should check the client's most recent potassium value because these findings are manifestations of hyperkalemia, which can lead to cardiac dysrhythmias.

A nurse is teaching a client who has Raynaud's disease. Which of the following pieces of information should the nurse include in the teaching? A. Protect against the cold by wearing layers of clothing B. Begin an exercise program of 2-mile walks once per week C. Increase vitamin A in the diet D. Elevate the hands above heart level when resting

Client's who have raynaud's disease are prone to attacks during cold weather. Extreme cold can lead to tissue damage. Therefore, the client needs to be protected with layers of clothing to promote warmth and increase circulation to the extremitites.

A nurse is reviewing the medical history of a client who is scheduled for a magnetic resonance imaging (MRI) examination of the cervical vertebra. Which of the following pieces of information in the client's history is a contraindication to this procedure? A. The client has a new tattoo. B. The client is unable to sit upright C. The client has a history of peripheral vascular disease D. The client ha a pacemaker.

D. An MRI uses strong magnets and radio waves that are evaluated using computer technology to view 3D images of the body. Since an MRI is magnetically generated, it is not indicated for use in the presence of certain medical implants. Clients who have cerebral aneurysm clips, cardiac pacemakers, or internal defibrillators cannot undergo an MRI because the strong magnetic force can interfere with these devices and obscure surrounding anatomical structures.

A nurse is caring for a client who has colitis and reported increased exacerbations due to stress at work. Which of the following responses should the nurse make? A. "I will contact the social worker so you can discuss career alternatives". B. "Have you thought about discussing the possibility of a part-time assignment with your employer". C. "Why don't you ask your employer to relieve you of some work until you are stronger?" D. "Perhaps we should review your coping mechanisms and talk about other alternatives."

D. Reviewing coping mechanisms and alternative coping patterns will promote coping skills that can assist the client in reducing stress.

A nurse is reviewing a client's repeat laboratory results 4 hrs after administering fresh frozen plasma (FFP). Which of the following laboratory results should the nurse review? A. Prothrombin time B. WBC count C. Platelet count D. Hematocrit.

The nurse should review the client's prothrombin time after the administration of FFP which is plasma-rich in clotting factors. FFP is administered to treat acute clotting disorders. The desired effect is a decrease in the prothrombin time.