Med Surg 2 4210 practice-ati

a nurse is having difficulty caring for a client due to variable affecting the communication process. which should the nurse identify as an interpersonal variable? SATA

Education Gender Perception

A nurse is caring for a client who is scheduled to have a MRI scan. The client asks the nurse what to expect during the procedure. which of the following statements should the nurse make?

"An MRI scan is very noisy and you will be allowed to wear earplugs while in scanner." (earplugs are offered to reduce discomfort. MRI lasts 60-90 mins. Contrast dye is not used in MRI. Can be distorted with movements so client has to lie still).

A nurse is reviewing the laboratory results for a client who has a history of atherosclerosis and notes elevated cholesterol levels. which of the following statements by the client indicates the nurse should plan follow-up teaching on low cholesterol diet?

"I eat two eggs for breakfast each morning" (the client should limit egg yolks to 2-3 times per week)

A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. which of the following statements by the client indicates a need for further teaching?

"I'll be glad when I can stop taking this medicine" (commonly required for lifetime administration and should not be stopped without the advice of client's provider)

A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches the client states, "I am feeling really down and don't want to talk to anyone right now." which of the following responses should the nurse make?

"Ill just sit here with you for a few minutes then" (this is a therapeutic response as an example of offering self; client can talk if they want to)

A nurse is caring for a client who is taking naproxen following an exacerbation of RA. which of the following statements requires further discussion by the nurse?

"Ive been taking an antacid to help with indigestion" (NSAIDS like naproxen can cause serious adverse GI reactions-should be reported to the nurse if having indigestion)

A nurse is educating a group of clients about the contraindications of warfarin therapy. which of the following statements should the nurse include in the teaching?

"clients who are pregnant should not take warfarin" (risk for bleeding)

CLient has difficulty swallowing enteric coated aspirin PO. Response to client asking if it can be crushed

"crushing the medication may cause you to have a stomachache or indigestion"

A nurse is caring for a client who reports taking bisacodyl to promote daily BM. Which of the following questions is a priority for the nurse to ask?

"how long have you been taking the bisacodyl

A nurse is teaching a client who is lactose intolerant. which of the following statements regarding lactose intolerance should the nurse include in the teaching plan?

"you should decrease the dairy products in your diet"

A nurse is assessing four female clients for obesity. which of the following clients have manifestations of obesity

A client who weighs 28% above ideal body weight (obesity is classified as a weight 20% or greater than ideal weight, 88.9 cm circumference, BMI greater than 28)

A nurse is admitting a client who has active TB to a room on the med surg unit. which of the following room assignments should the nurse make for the client

A room with air exhaust directly to the outdoor environment (this type of ventilation system is referred to as an airborne infection isolation room; won't contaminate other client care areas)

A nurse is preparing a teaching plan for a client who has neutropenia as a result of radiation therapy for the treatment of lung cancer. Which of the following should the nurse plan to include in the teaching?

Bottled water is an appropriate choice to increase fluid intake (clients who have neutropenia are at risk for foodborne illness. bottled water prevents the client exposure to pathogens that may be found in other water sources)

A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?

CD4-T-Cell count of 180 cells/mm3 (indicates that the client is severly immunocompromised and at high risk for infection)

A nurse is caring for a client who has a prescription for olanzapine. the nurse should monitor the client for which of the following manifestations as an expected response to this medication)

Decreased auditory hallucinations (prescribed for the treatment of manifestations of schizophrenia, one of which is auditory hallucinations)

A nurse is assessing a client who has malnutrition. which of the following findings should the nurse expect?

Decreased mental status

A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring UTI. which of the following actions should the nurse include in the clients plan of care?

Encourage fluid intake at and between meals

A nurse is caring for a client who has a new diagnosis of urolithiasis. which of the following should the nurse identify as an associated RF?

Family History (Family history is strongly correlated to urolithiasis, nurse should assess the client who has kidney stones for familial tendencies toward stone formation. Hypercalcemia is RF. BMI greater than 29 is RF. medications such as antacids, laxatives, vitamin D, and aspirin are RF)

Pt has severe burn injury and is receiving IV fluid resuscitation therapy. which finding indicates adequate fluid replacement

HR

A nurse is caring for a client who has had a stroke involving the right hemisphere. which of the following alterations should the nurse expect

Inability to recognize his family (right hemisphere is involved with visual and spatial awareness. a client who is unable to recognizes faces would be R/T right hemisphere)

A nurse is assessing a client who is taking levothyroxine. the nurse should recognize that which of the following findings is a manifestation of levothyroxine overdose?

Insomnia (overdose will result in manifestations of hyperthyroidism which include insomnia, tachycardia, and hyperthermia)

A nurse is caring for a client who has prostate cancer. the nurse should expect the provider to prescribe which of the following medications for this client?

Leuprolide (treats cancer of the prostate hormonally. it antagonizes the androgens that androgen dependent neoplasms require)

renal failure expected ABGs

Metabolic acidosis low HCO3, low pH, normal PaCo2

A nurse is caring for a client who has type 1 DM. which of the following recommendations should the nurse make to the client for a sweetner?

Nonnutritive Sugar Substitute (Clients with T1DM should limit carbohydrate intake, which this allows)

Nurse is admitting a client who has acute pancreatitis. which of the provider prescriptions should the nurse anticipate

Pantoprazole 80 mg IV bolus twice daily (PPI: dec gastric acid production, ultimately decreases pancreatic secretions(

A nurse caring for an adolescent client who has newly applied fiberglass cast for a fractured tibia. which of the following is the priority action for the nurse to take.

Perform a neurovascular assessment

A nurse is caring for a client who was admitted with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding. Which of the following actions should the nurse take?

Provide frequent oral and nares care. (Client is unable to swallow. If the client is alert, the nurse should encourage the client to spit saliva into tissue or basin. If client is not alert, gentle suctioning may be required to remove secretions)

A nurse is caring for an adolescent who has hemophilia A and is scheduled for wisdom teeth extractions. prior to the procedure, the nurse should anticipate that the client will receive which of the following products

Recombinant (replace deficient factor as prophylactic measure)

A nurse is teaching a client who has pre-dailysis end-stage kidney disease about diet. Which of the following instructions should the nurse include?

Reduce intake of foods high in potassium (Client should reduce foods high in potassium because potassium clearance is impaired in the client who has end-stage kidney disease)

A nurse is caring for a client who is discussing his PTSD and state: "everyone thinks you should be able to put it out of your mind. it happened so long ago-just get over it". The nurse responds, "it must be very frustrating to encounter this kind of attitude" the nurse is using which if the following therapeutic communication techniques?

Reflection (responding to the content and emotional components of a message by restating the clients feelings)

A nurse is providing dietary teaching for a client who has just learned that she has T2DM. the nurse should explain that which of the following sweeteners will ass calories to the client's carbohydrate count?

Sorbitol (provides calories just as sucrose does)

A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's BP is 80/64 mmHg. which of the following actions should the nurse take first.

Stop the infusion of the blood. (the client is experiencing an acute intravascular hemolytic transfusion reaction. the greatest risk to this client is receiving additional blood, therefore the first action is to stop the infusion)

A nurse is assessing a client who sustained. basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first?

Test the drainage for glucose (priority nursing action because of the high risk of CSF leak in the client with basal skull fractures, the nurse should realize there is a possibility that the clear fluid coming is CSF, which will test positive for glucose)

a hospice nurse is caring for a client who has terminal cancer and take PO morphine for pain relief. the client reports that he had to increase the dose of morphine this week to obtain pain relief. which of the following scenarios should the nurse document as the explanation for this situation?

The client developed a tolerance to the medication

A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzyme studies?

These test help determine the degree of damage to heart tissues (degree of damage to the myocardium, commonly measured are CPK and Troponin)

A nurse is caring for a client who has bipolar disorder and has been taking lithium for 1 year. before administering the medication, the nurse should ask to see that which of the following tests have been completed?

Thyroid Hormone Assay ( thyroid testing is important because long term use of lithium may lead to thyroid dysfunction)

A nurse caring for a client using active listening skills. which of the following actions should the nurse take?

Use intermittent eye contact (establish intermittent eye contact and maintain it during active listening. it demonstrates interest in what the client is saying.)

A nurse is reviewing the CBC findings for a female client who is receiving combination chemotherapy for breast cancer. which of the following findings should the nurse report to the provider?

WBC 2300/mm3 (below expected reference range and can cause leukopenia. Nurse should report to provider and implement precautions to protect client from infection)

A nurse is assessing a client who is postoperative following an abdominal surgery. which of the following findings should the nurse report to the provider?

Yellow-green drainage on the surgical incision (thick yellow-green drainage is indicative of an infection and should be reported immediately)

A client who has chronic lymphocytic leukemia is starting chemotherapy treatments and asks if she needs to make any dietary changes. which of the following statements should the nurse make?

You should avoid drinking liquids an hour before the treatments (fluids may cause N/V)

A nurse is caring for a client who has developed gout. which of the following medications should the nurse prepare to administer

allopurinol (an xanhene oxidse inhibitor that reduces uric acid synthesis)

the family of an older adult client brings him in to the ED after finding him wandering outside. during the initial assessment, the nurse notes that the client flinches when she palpates his abdomen yet responds to questions only by nodding and smiling. which of the following factors should the nurse identify as a likely explanation of the client's behavior?

confusion

Expected findings for client with liver failure with ascites and is receiving spironolactone

decreased sodium level

medications that cause risk for orthostatic hypotension

furosemide telmisartan duloxetine

Nurse recommends which of the following foods as the best source of protein that promotes wound healing (vegaN

one cup of lentils

Which medications can cause glucose intolerance

prednisone

a nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. the client had intermaxillary fixation to repair and stabilize the fraction. which of the following actions is the priority for the nurse to take?

prevent aspiration

A nurse is teaching a class about medication reconciliation. which of the following information should the nurse include in the teaching

provide a list of the client's current medications during admission into health care facility.

A nurse is caring for a client who is undergoing a lumbar puncture. which of the following is the priority action for the nurse to take to maintain privacy for the client

pull the curtains around the clients bed

Which outcome indicates H2RA is therapeutic

relief of heartburn

A nurse is reviewing lab values for a client who has SLE. which of the following values should give the nurse the best indication of the client's renal function?

serum creatinine

A nurse is caring for a client who is to start therapy with ibuprofen for hip pain. which of the following information should the nurse provide about ibuprofen?

take the medicaiton with food

A nurse is caring for a client who has chemotherapy-induced peripheral neuropathy. the nurse should expect the client to report having experience which of the following symptoms?

tingling feeling in the extremities

A nurse is teaching a client who is taking atorvastatin daily. Which of the following statements by the client indicates an understanding of the teaching

"I will avoid drinking grapefruit juice" (grapefruit cna reduce metabolism of atorvastatin, which increases the risk for toxicity)

A nurse in a public clinic is planning a health fair for older adult clients in the community. in teaching medication safety, which of the following foods should the nurse advise to avoid when taking their prescriptions?

grapefruit juice

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. the nurse should monitor the client for which of the following complications (SATA):

-Hypotension (lack of sympathetic input can cause dec. in BP. nurse should maintain a SBP of 90 mmHg or higher to adequately perfuse the spinal cord) -Absence of bowel sounds (spinal shock leads to decreased peristalsis, which could cause a paralytic ileus to develop) -Weakened gag reflex (monitor for difficulty swallowing, coughing and drooling noted with oral intake) [monitor for bladder distention/inability to urinate and hypothermia]

A nurse is assessing a client who has fluid overload. which of the following findings should the nurse expect? (SATA):

-Inc HR (tachycardia and inc cardiac contractility in response to excess fluid) -Inc BP (inc BP and bounding pulse in response to excess fluid). -Inc RR (moist crackles heard in lungs)

A nurse is caring for a client who is at risk for falls. which of the following actions should the nurse take (SATA):

-Teach the client to use the call light -Keep the client's bed in lowest position -Place a fall-risk identification band on the client's wrist

A nurse on an inpatient eating disorders unit is caring for a client who has anorexia nervosa and a BMI of 17.2. which of the following actions should the nurse take? SATA

-provide the client with small meals frequently -monitor the clients weight daily -stay with the client during meals and for 1 hour after -offer specific privileges for sustained weight gain

A nurse is teaching the class about safe medication administration. the nurse should include in the teaching that which of the following references are acceptable for safe medication administration? SATA

-published journals -pharmacists -physician's desk reference

A nurse in a clinic is assessing a client who has AIDS and a significantly decreased CD4-T-cell count. The nurse should recognize that the client is at risk for developing which of the following infectious oral conditions?

Candidiasis (can affect anyone and clients whose immune systems have been compromised by illness such as AIDS or medications)

A nurse is completing discharge teaching with a client following arthroscopic knee surgery. which of the following instructions should the nurse include in the teaching?

Apply ice to the affected area (applying ice to the affected area in the immediate postop period [first 24hr] reduces pain and swelling. joint use should be minimized first few days. should not overuse or strain joint. elevate the affective area reduces pain and swelling)

A nurse is caring for a client who has CHF and is taking digoxin daily. the client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?

Check the client's vital signs. (nausea is secondary to digoxin toxicity. by obtaining vital signs the nurse can assess for bradycardia, which is a symptom of digoxin toxicity. the nurse should withhold the medication and call the provider if HR is less than 60 BPM)

A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidectomy. the client reports a tingling sensation in the hands , the soles of feet, and around the lips. which of the following findings should the nurse assess the client?

Chvostek's signs (suspect the client has hypocalcemia)

A nurse is caring for a client who is taking lisinopril. which of the following outcomes indicates a therapeutic effect of the medication?

Decreased blood pressure (lisinopril is an ACE inhibitor use to manage hypertension and CHF.)

a nurse is teaching a client who takes acetaminophen daily to manage mild knee pain. the nurse should instruct the client to monitor for which of the following adverse reactions to this medication

Jaundice

A nurse is administering a tap water enema to a client who is constipated. during administration of the enema, the client states he is having abdominal cramps. which of the following actions should the nurse take to relieve the clients discomfort?

Lower the height of the solution container (if nausea or cramping occurs, the flow of water should momentarily be slowed or stopped by lowering the device of clamping the tubing)

A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). when assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. which of the following actions should the nurse take first?

Measure the circumference of both upper arms. (the first action the nurse should take using the nursing process is to assess the client, the nurse should measure the arm and compare the result with the circumference of the other arm. if the arm is swollen then notify the provider who inserted it.)