Med-Surg ATI

A nurse is planning care for a client who had a stroke. The client has hemiplegia and occasional urinary incontinence. Which of the following actions should the nurse include in the client's plan of care? A. Offer the client a bedpan every 2 hr B. Limit the client's daily fluid intake until he is no longer incontinent C. Request a prescription for an indwelling urinary catheter from the client's provider D. Ambulate the client to the bathroom every 30 min

A. Offer the client a bedpan every 2 hr

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 make? (Select all that apply) 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

A nurse is performing an admission assessment for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first? A. Document the client's food allergies on the medical record B. Ask the client to identify specific food allergies C. Monitor the client for indications of anaphylaxis D. Have epinephrine available for administration

B. Ask the client to identify the specific food allergies

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 for the client's blood glucose level D. Discuss long-term complications that can result from nonadherence to the dietary plan

B. Ask the client to identify the types of foods she prefers

A nurse is caring for a client who has encephalitis due to West Nile virus. Which of the following actions should the nurse take? (Select all that apply) A. Place the client on respiratory isolation B. Monitor vital signs every 2 hr C. Assess neurological status every 4 hr D. Maintain the client in a modified Trendelenburg position E. Keep the client's room darkened

B. Monitor vital signs every 2 hr C. Assess neurological status every 4 hr E. Keep the client's room darkened

A nurse is caring for a client who is to have his chest tube removed. Which of the following actions should the nurse take? A. Cover the insertion site with a hydrocolloid dressing after removal B. Provide pain medication immediately after removal C. Instruct the client to perform the Valsalva maneuver during removal D. Delegate removal of the chest tube to a LPN

C. Instruct the client to perform the Valsalva maneuver during removal

A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which of the following actions should the nurse take? A. Have the client gently blow clots from the nose every 5 min B. Instruct the client to sit with his head hyperextended C. Apply ice compresses to the back of the client's neck D. Apply lateral pressure to the client's nose for 10 min

D. Apply lateral pressure to the client's nose for 10 min.

A nurse in an emergency department is caring for a client who reports developing severe right eye pain with a gritty sensation while sawing wood. Which of the following actions should the nurse take first? A. Instill proparacaine hydrochloride eyedrops B. Perform ocular irrigation of the right eye C. Place the client in a supine position with the head turned toward the affected side D. Ask the client about first aid performed at the scene

D. Ask the client about first aid performed at the scene.

A nurse is providing postoperative care for a client who has two chest tubes in place following a lobectomy. The client asks the nurse the reason for having two chest tubes. The nurse should inform the client that the lower chest tube is placed for which of the following reasons? A. Removing air from the pleural space B. Creating access for irrigating the chest cavity C. Evacuating secretions from the bronchioles and alveoli D. Draining blood and fluid from the pleural space

D. Draining blood and fluid from the pleural space

A nurse is planning care for a client during a sickle cell crisis. Which of the following interventions should the nurse include in the client's plan of care? A. Maintain the client's knees and hips in a flexed position B. Apply cold compresses to painful joints C. Withhold opioids until the crisis is resolved D. Encourage increased fluid intake

D. Encourage increased fluid intake.