ATI Med-Surg

A nurse in the emergency department is assessing a client who has pancreatitis. In which of the following laboratory results should the nurse expect to see an elevation? a. Amylase b. Potassium c. Calcium d. Hematocrit

a. Amylase

A nurse is caring for a client who is 3 days postoperative following abdominal surgery. The client states, "Something just popped when I coughed." Which of the following actions should the nurse take first? a. Cover the client's wound with a sterile, moist dressing b. Flex the client's knees c. Reassure the client d. Instruct the client to avoid coughing

a. Cover the client's wound with a sterile, moist dressing

While participating in a community health fair, a nurse is providing information to a client who has a blood pressure of 150/90 mmHg during screening. Which of the following actions should the nurse take? a. Give the client a written record of his BP to bring to his provider b. Encourage the client to go to the nearest emergency department c. Instruct the client to follow-up with a provider within 6 months d. Explain to the client that he is not at risk unless he has manifestations of hypertension

a. Give the client a written record of his BP to bring to his provider

A nurse is planning postoperative education for a client who will undergo a radical neck dissection for cancer of the larynx. The nurse should include which of the following topics? (Select all that apply.) a. NPO status b. Alternative methods of communication c. Endotracheal intubation d. Changes in body image e. Swallowing exercises

a. NPO status b. Alternative methods of communication d. Changes in body image e. Swallowing exercises

A nurse is caring for a client who had a gastric resection to treat adenocarcinoma of the stomach. The client tells the nurse in the PACU that he does not remember why the surgeon said he had to have a tube in his nose. The nurse should explain that the NG tube serves which of the following purposes? a. Prevents excessive pressure on suture lines b. Allows gastric lavage after surgery c. Allows early postoperative feeding d. Facilitates obtaining gastric specimens for testing

a. Prevents excessive pressure on suture lines

A nurse is caring for a client who has a traumatic brain injury and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing a blood sample? a. The client rigidly extends his arms. b. The client internally flexes his wrists. c. The client curls into a fetal position. e. The client internally rotates his legs.

a. The client rigidly extends his arms.

A nurse is providing discharge teaching about improving gas exchange for a client who has emphysema. Which of the following instructions should the nurse include in the teaching? a. Use pursed-lip breathing during periods of dyspnea b. Limit fluid intake to 1,500 mL per day c. Practice chest breathing each day d. Wear home oxygen to maintain an SaO2 of at least 94%

a. Use pursed-lip breathing during periods of dyspnea

A nurse is completing dietary teaching with a client who has heart failure and is prescribed a 2 g sodium diet. Which of the following statements by the client indicates an understanding of the teaching? a. "I should use salt sparingly while cooking." b. "I can have yogurt as a dessert." c. "I should use baking soda when I bake." d. "I should use canned vegetables instead of frozen."

b. "I can have yogurt as a dessert."

A nurse is teaching a client who is on bed rest about preventing complications. Which of the following client statements indicates an understanding of the teaching? a. "I should perform range-of-motion exercises once per day." b. "I should cough and deep-breathe every hour." c. "I should change my position every 4 hours." d. "I should perform foot and ankle pumps every 3 hours."

b. "I should cough and deep-breathe every hour."

A nurse is providing teaching to a client who has stomatitis due to chemotherapy and radiation therapy. Which of the following statements by the client indicates a need for further teaching? a. "I will use a soft toothbrush or foam swab for oral care." b. "I will use lemon and glycerin swabs after meals." c. "I will remove my dentures except while eating." d. "I will rinse my mouth frequently with hydrogen peroxide solution."

b. "I will use lemon and glycerin swabs after meals."

A nurse is obtaining a guaiac test from a client. This test is performed to detect which of the following? a. Fecal material in vomit b. Blood in stool c. Infestation of parasites d. Microorganisms in urine

b. Blood in stool

A nurse is planning care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan of care? a. Restrict fluids to 1,000 mL per day b. Measure the client's abdominal girth daily c. Check IV sites every 4 hr for bleeding d. Administer an enema as needed for constipation

b. Measure the client's abdominal girth daily

A nurse is transfusing a unit of B-positive fresh frozen plasma to a client whose blood type is O-negative. Which of the following actions should the nurse take? a. Continue to monitor for manifestations of a transfusion reaction b. Remove the unit of plasma immediately and start an IV infusion of normal saline solution c. Continue the transfusion and repeat the type and crossmatch d. Prepare to administer a dose of diphenhydramine IV

b. Remove the unit of plasma immediately and start an IV infusion of normal saline solution

A nurse is caring for a client who is 3 days postoperative following a below-the-knee amputation. Which of the following actions should the nurse take? a. Place the client on a soft mattress b. Rewrap the residual limb with a bandage 3 times per day c. Assist the client into a prone position for 20 min every 8 hr daily d. Turn the client every 4 hr while in bed

b. Rewrap the residual limb with a bandage 3 times per day

A nurse is caring for a client who begins to have a generalized tonic-clonic seizure while lying in bed. Which of the following actions should the nurse take? a. Insert an oral airway b. Turn the client onto a side c. Restrict movement of the client's limbs d. Place a pillow under the client's head

b. Turn the client onto a side

A nurse is preparing a client who is scheduled for an intravenous pyelogram (IVP). Which of the following findings should the nurse report to the provider? a. Allergy to egg products b. Vomiting and diarrhea for the last 6 hr c. Serum potassium of 3.6 mEq/L d. Serum creatinine of 1.2 mg/dL

b. Vomiting and diarrhea for the last 6 hr

A nurse is providing preoperative teaching for a client with colorectal cancer who is scheduled to undergo colostomy placement with a perineal wound. Which of the following statements by the client indicates an understanding of the teaching? a. "Not having any more rectal pain will be a relief." b. "I will need to sit on a rubber donut when I am in the chair." c. "I can have only liquids for 2 days before the surgery." d. "The colostomy will start working about 7 days after the surgery."

c. "I can have only liquids for 2 days before the surgery."

A nurse is teaching a client who was recently diagnosed with Raynaud's disease about preventing the onset of manifestations. Which of the following statements by the client indicates an understanding of the teaching? a. "I should limit my exposure to sunlight." b. "I should avoid drinking alcohol." c. "I should not smoke." d. "I should limit of intake of foods that are high in purine."

c. "I should not smoke."

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 help you experience less pain."

c. "Variant angina can cause changes on your electrocardiogram."

A nurse is assessing a client who is receiving hemodialysis for the first time. Which of the following findings indicates that the client is developing dialysis disequilibrium syndrome (DDS)? a. Elevated BUN b. Bradycardia c. Headache d. Temperature 39.2°C (102.5°

c. Headache

A nurse is caring for a client who had a left lower lobectomy to treat lung cancer. Which of the following factors will have a significant impact on the plan of care for this client? a. The client will need intensive smoking-cessation education. b. After surgery, the prognosis for clients with lung cancer is usually good. c. Lung cancer usually has metastasized before the client presents with symptoms. d. Oxygen therapy is ineffective following a lobectomy.

c. Lung cancer usually has metastasized before the client presents with symptoms.

A nurse is planning care for a client following a total hip arthroplasty. Which of the following interventions should the nurse include in the plan? a. Position the client with her legs adducted b. Internally rotate the client's affected hip c. Place a pillow between the client's legs d. Instruct the client to avoid flexing her hip more than 95º

c. Place a pillow between the client's legs

A nurse is providing teaching about food choices to a client who has diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? a. "I will need to eliminate sweet desserts from my diet." b. "I should avoid using sucralose in my coffee." c. "I should consume alcohol between meals in moderation." d. "I should replace white bread with whole-grain bread."

d. "I should replace white bread with whole-grain bread."

A nurse is providing discharge teaching to a client who is postoperative following a rhinoplasty. Which of the following instructions should the nurse include? a. "Apply warm compresses to the face." b. "Take aspirin 650 mg by mouth for mild pain." c. "Close your mouth when sneezing." d. "Lie on your back with your head elevated 30° when resting."

d. "Lie on your back with your head elevated 30° when resting."

A nurse is caring for a client who has regular occupational exposure to sunlight and presents for evaluation of several skin lesions. Which of the following findings should alert the nurse to the possibility of malignant melanoma? a. A pearly papule that is 0.5 cm (0.20 in) wide with raised, indistinct borders on the upper right shoulder b. Several flat, pigmented, circumscribed areas of various sizes over the bridge of the nose c. A raised, circumscribed lesion on the face that contains yellow-white purulent material d. An irregularly shaped brown lesion with light blue areas on the neck

d. An irregularly shaped brown lesion with light blue areas on the neck

A nurse is reviewing the medical record of a female client. Which of the following findings should the nurse identify as a risk factor for osteoporosis? a. Decreased intake of phosphate-containing foods b. Spending several hours in the sun daily c. Increased estrogen levels d. History of anorexia nervosa

d. History of anorexia nervosa

A nurse is assessing a client who has acute kidney injury (AKI). According to the RIFLE classification system, which of the following findings indicates that the client has end-stage kidney disease? a. <0.5 mL/kg of urine output for 12 hr b. No urine output for 12 hr c. No urine output without renal replacement therapy for 4 to 12 weeks d. No urine output without renal replacement therapy for more than 3 months

d. No urine output without renal replacement therapy for more than 3 months

A nurse is caring for a client who has a left intracranial hemorrhage from a stroke. Which of the following findings should the nurse expect? a. Spasticity of the left foot b. Negative Babinski reflex c. Ocular hypertension d. Right-sided hemiplegia

d. Right-sided hemiplegia

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

A nurse observes tachycardia, dyspnea, a cough, and distended neck veins in a client who is receiving a transfusion of packed red blood cells (RBCs). Which of the following interventions should the nurse use to prevent these manifestations with the client's next transfusion? a. Warm the unit of blood to room temperature before administering it b. Administer acetaminophen prior to the blood transfusion c. Give an antihistamine prior to the transfusion d. Use a transfusion pump to regulate and maintain the transfusion at a slower rate

d. Use a transfusion pump to regulate and maintain the transfusion at a slower rate