ati capstone post study quiz med surg assessment 1

a nurse is providing teaching to a client who has asthma and a new prescription for prednisone. which of following client statements indicates an understanding of teaching?

"I will take this medication with meals." The nurse should identify that this client statement indicates an understanding of the teaching. The nurse should instruct the client to take the medication with food or meals to prevent nausea and vomiting. The nurse should inform the client that this medication has the potential for causing weight gain rather than weight loss.

a nurse is providing discharge teaching to a client who has tuberculosis and a new prescription for rifampin. which of following instructions should the nurse include?

"Your urine will be an orange color while taking this medication." The nurse should instruct the client to expect their urine to appear orange in color because this is an adverse effect of rifampin. An adverse effect of rifampin is drowsiness; therefore, the nurse should instruct the client to avoid driving or participating in activities that require alertness. The nurse should instruct the client that rifampin should be taken on an empty stomach 1 hr before or 2 hr after meals with a full glass of water for optimal absorption.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). which of following actions should the nurse take?

Monitor the client's weight daily. The nurse should monitor the client's weight daily to ensure fluid overload, congestive heart failure, or pulmonary edema are not developing. The nurse should also keep a strict record of the client's intake and output while receiving TPN and report any significant changes to the provider immediately. The nurse should infuse TPN through a central vein. TPN can be administered through a peripherally inserted central catheter line or a central line using the subclavian or internal jugular veins. The nurse should obtain a blood glucose level every 4 hr while the client is receiving TPN. TPN can increase a client's blood glucose level, resulting in required administration of insulin. The nurse should change the tubing every 24 hr. This action prevents the client from acquiring a bacterial infection from contaminated tubing.

A nurse is planning nutrition for a client who has Parkinson's disease (PD). Which of the following action should nurse take

Offer the client high-protein foods. The nurse should offer high-protein and high-calorie foods to a client who has Parkinson's disease. Clients who have Parkinson's disease can have trouble maintaining their weight due to difficulty with eating and swallowing. Providing foods with high protein and high calories can assist in maintaining the client's weight and nutritional needs.

A nurse is preparing to administer peritoneal dialysis to a client. Which of the following actions should the nurse take?

Use sterile technique when connecting the dialysate tubing. The nurse should identify that a common complication of peritoneal dialysis is peritonitis. Therefore, to prevent infection, the nurse should use strict sterile technique when connecting the dialysate tubing. Warming the client's dialysate to room temperature can decrease the risk of stomach pain. The nurse should place the dialysate on a heating pad or in a warming chamber prior to administration. The nurse should ensure the client is in a supine, low-Fowler's position throughout the procedure. The nurse should place the dialysis drainage bag below the level of the client's abdomen. This positioning promotes dialysis drainage by gravity.

a nurse is reviewing the laboratory report of a client who has COPD. which of following ABG results should the nurse identify as an indication of respiratory acidosis?

pCO2 55 mm Hg The nurse should identify that a client who has COPD will have an increased pCO2 level as an indication of respiratory acidosis. The expected reference range for pCO2 is 35 to 45 mm Hg. decreased pH as an indication of respiratory acidosis. The expected reference range for pH is 7.35 to 7.45 will have a decreased PO2 as an indication of respiratory acidosis. The expected reference range for PO2 is 80 to 100 mm Hg.

a nurse is providing discharge teaching to a client who is postop following a permanent pacemaker. which of following statements should nurse take?

"Notify your provider if you experience prolonged hiccupping." The nurse should instruct the client to notify the provider if constant hiccupping occurs. This can be an indication of pacemaker lead displacement and should be reported to the provider immediately. keep incision site free from pressure dressings and tight or constricting garments because these can impair proper functioning of pacemakers generator and delay healing.

a nurse is assessing a client who experienced a stroke. which of following manifestation should indicate to the nurse that the client experienced a left hemispheric stroke?

Aphasia The nurse should identify that a client who experienced a left hemispheric stroke can exhibit aphasia, which is the inability to speak. Other manifestations can include memory loss, problems with reading, slowness, depression, and anxiety when attempting new tasks. The nurse should identify that a client who has experienced a right hemispheric stroke can exhibit a loss of depth perception. Other manifestations can include hearing loss, constant smiling, disorientation to time and place, and poor judgment.

A nurse is creating a plan of care for a client who has a deep-vein thrombosis (DVT). Which of the following interventions should nurse include?

Apply warm, moist packs to the client's affected leg. The nurse should apply warm, moist packs to the client's affected extremity to assist with dissolving the clot as well as providing comfort. The nurse should encourage the client to elevate their legs while lying in bed or sitting in a chair. This action promotes venous return to the affected extremity. The nurse should avoid massaging the client's affected extremity. This action increases the risk of clot dislodgement, which can result in a pulmonary embolus. The nurse should avoid placing a pillow under the client's knees while in bed. This action can constrict the flow of blood to the extremities and increases the risk for further deep vein thrombosis.

A nurse is assessing a client who has heart failure. which of following findings should the nurse identify as an indication that the client is experiencing fluid overload?

Bounding pulse The nurse should identify a bounding pulse as a manifestation of fluid overload. Other manifestations of fluid overload can include weight gain, hypertension, distended neck veins, pitting edema of the lower extremities, and shortness of breath.

a nurse is assessing a client immediately following a lumbar puncture. which of following findings should nurse report to the provider?

Client reports feeling nauseated The nurse should identify that nausea is a manifestation of increased intracranial pressure (ICP) and can be due to a decrease of cerebrospinal fluid within the cranium. Other manifestations of increased ICP are a severe headache, vomiting, photophobia, and a change in level of consciousness. The nurse should notify the provider of any of these findings immediately.

A nurse is planning care for a client who has meningitis. Which of the following intervention should the nurse plan to include?

Maintain the head of the client's bed at a 30° angle. The nurse should increase the head of the client's bed to 30° and ensure the client remains on bed rest. A client who has meningitis is at an increased risk for experiencing increased intracranial pressure; therefore, maintaining the head of the bed to 30° can prevent this life-threatening medical emergency. The nurse should obtain the vital signs every 2 to 4 hr for a client who has meningitis. The nurse should also monitor the client closely for fever, tachycardia, and changes in blood pressure. The nurse should perform passive range-of-motion exercises to the client's extremities every 4 hr. Clients who have meningitis experience muscle aches and pains as a manifestation of this condition. The nurse should keep the client's room dark with minimal exposure to light. Clients who have meningitis experience headaches, photophobia, and phonophobia.

a nurse is caring for a client who is scheduled for a thoracentesis. which of following actions should the nurse take?

Monitor the client's heart rate during the procedure. The nurse should monitor the client's heart rate during the procedure to ensure that the client does not experience reflex bradycardia. The nurse should also monitor for diaphoresis and instruct the client to report feeling lightheaded immediately.

a nurse is assessing a client who has a duodenal ulcer due to peptic ulcer disease. which of following findings should the nurse expect?

Pain during the middle of the night A client who has a gastric ulcer will rarely report experiencing pain during the middle of the night. The nurse should identify that awakening during the middle of the night due to pain is a manifestation of a duodenal ulcer. Pain often occurs between the hours of 0100 and 0200. ( typically well nourished, reports relief of pain with eating) pt with gastric ulcer will report receiving no pain relief from the ingestion of antacids, will report increased pain with eating; Malnourishment and weight loss are manifestations of a gastric ulcer.

A nurse is providing teaching to a client who has hypertension and a new prescription for lisinopril. Which of the following adverse effect of lisinopril should nurse instruct client to report to provider?

Persistent cough The nurse should instruct the client to monitor for adverse effects of lisinopril, which can include a persistent cough, decreased blood pressure, taste disturbances, and dizziness. The client should report a persistent cough to the provider because this could lead to angioedema and airway obstruction.

a nurse is preforming a preoperative assessment on a client who reports an allergy to eggs. nurse should identify which of following medications is contraindicated for this client?

Propofol The nurse should identify that an allergy to egg lecithin, soybean oil, peanuts, or glycerol is a contraindication for the client receiving propofol. The nurse should notify the provider of the allergy and ensure the client is wearing an allergy alert bracelet.

a nurse is assessing a client who has atrial fibrillation. which of following findings should indicate to nurse that the client might be experiencing left-sided heart failure?

Pulmonary congestion The nurse should identify pulmonary congestion as a manifestation of left-sided heart failure. As the left ventricle fails to eject blood properly, pressure builds up in the pulmonary system, resulting in congestion and a cough. As heart failure worsens, pulmonary edema can develop. Other manifestations of left-sided heart failure can include oliguria, weakness, fatigue, dyspnea, S3 gallop, tachycardia, cool extremities, and weak peripheral pulses.

a nurse is providing dietary teaching client who has new diagnosis of migraine headaches. which of following foods should nurse instruct client to avoid?

Smoked fish The nurse should instruct a client who has migraine headaches to avoid foods such as smoked fish and meats, which contain nitrates. Other foods that can cause a migraine attack include dairy products, caffeine, artificial sweeteners, aged cheeses, and other products that contain tyramine. Therefore, these foods should be avoided.

a nurse in ED is assessing client who was in motor vehicle crash. which of following findings should nurse identify as an indication client might have a tension pneumothorax?

Tracheal deviation The nurse should identify that tracheal deviation is a manifestation of a tension pneumothorax due to blunt trauma to the chest. The client's trachea is moved away from midline toward the unaffected side as injured tissues on the affected side cause a mediastinal shift. Tracheal deviation is a medical emergency that should be reported to the provider immediately.