ATI Med Surg 2023 A

A nurse is providing teaching to a female client who has stress incontinence and a BMI of 32. Which of the following statements by the client indicates an understanding of the teaching?

"A risk factor for my condition is obesity."

A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following interventions should the nurse include in the plan?

Encourage the client to take deep breaths after the procedure.

A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of the following precautions should the nurse implement?

Ensure that the client has a patent IV.

A nurse in the emergency department is caring for a client. Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

The client is experiencing manifestations of PANCREATITIS as evidenced by the AMYLASE AND LIPASE.

A nurse is caring for a client. Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

The client is experiencing manifestations of PERITONITIS due to X-RAY RESULTS.

The nurse is caring for the client. Complete the following sentence by using the lists of options. (Client has a penetrating wound to the anterior upper right chest.)

The client is most likely experiencing a HEMOTHORAX as evidenced by the client's RESPIRATORY FINDINGS.

A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following assessment findings should the nurse expect?

Hypoactive bowel sounds

A nurse in an emergency department is caring for a client who has full-thickness burns over 20% of their total body surface area. After ensuring a patent airway and administering oxygen, which of the following items should the nurse prepare to administer first?

IV fluids

A nurse is providing discharge instructions to a client following an upper gastrointestinal series with barium contrast. Which of the following information should the nurse provide?

Increase fluid intake.

A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pneumonia. Which of the following assessment findings is the nurse's priority?

Increased respiratory secretions

A nurse is caring for a client who is receiving dialysis treatment. For each potential nursing intervention, click to specify if the intervention is indicated or not indicated.

Indicated: - Place the client in Trendelenburg position. - Notify the provider immediately. - Administer a 0.9% sodium chloride 200 mL IV bolus. - Apply oxygen at 2 L/min via nasal cannula. Not Indicated: - Obtain the client's blood glucose level. - Perform a 12-lead ECG.

A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a productive cough. Which of the following actions should the nurse take first?

Initiate airborne precautions.

A nurse is administering packed RBCs to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction?

Low back pain and apprehension

A nurse is caring for a client who has terminal cancer. The client tells the nurse, "I wish I could stop these treatments. I am ready to die." Which of the following statements should the nurse make?

"Discontinuing with the treatments is your choice if it is your wish to do so."

A nurse is providing teaching to a client who takes ginkgo biloba as an herbal supplement. Which of the following statements should the nurse make?

"Ginkgo biloba can cause an increased risk for bleeding."

A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new prescription for metformin. Which of the following statements by the client indicates an understanding of the teaching?

"I should take this medication with a meal."

A nurse is providing discharge instructions to a client who has laryngeal cancer and is receiving radiation therapy. Which of the following statements by the client indicates an understanding of the teaching?

"I will avoid direct exposure to the sun."

A nurse is caring for a client in the emergency department (ED). For each finding below, click to specify if the finding is consistent with migraine, stroke, or meningitis. Each finding can support more than one disease process.

- Migraine: hand grasps, numbness, aphasia, visual changes, family history - Stroke: hand grasps, numbness, aphasia, visual changes, family history - Meningitis: hand grasps, visual changes

A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching?

"I will monitor my blood pressure while taking this medication."

A nurse is providing preoperative teaching for a client who is scheduled for a mastectomy. Which of the following statements should the nurse make?

"I will refer you to community resources that can provide support."

A nurse is teaching a group of newly licensed nurses about pain management for older adult clients. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?

"Ibuprofen can cause gastrointestinal bleeding in older adult clients."

A nurse in an emergency department is assessing a client who has a detached retina. Which of the following should the nurse expect the client to report?

"It's like a curtain closed over my eye."

The nurse is caring for the client. The nurse is caring for the client following the placement of a chest tube for a hemothorax. Which of the following actions should the nurse take? Select all that apply.

- Place the client in high-Fowler's position. - Place two rubber-tipped hemostats in the client's room. - Palpate the chest tube insertion site for subcutaneous emphysema. - Ensure that all chest tube connections are securely attached.

A nurse is caring for a client who has homonymous hemianopsia as a result of a stroke. To reduce the risk of falls when ambulating, the nurse should provide which of the following instructions to the client?

"Scan the environment by turning your head from side to side."

A nurse is providing teaching to a client who has cancer and a new prescription for an opioid analgesic for pain management. Which of the following information should the nurse include in the teaching?

"You should void every 4 hours to decrease the risk of urinary retention."

A nurse is providing teaching to a client who has stage II cervical cancer and is scheduled for brachytherapy. Which of the following instructions should the nurse include?

"You will need to stay still in the bed during each treatment session."

The nurse is caring for a client who has a migraine. The nurse is evaluating the client's understanding of discharge instructions. Which of the following client statements indicates an understanding of the teaching? Click to highlight the findings that indicate client understanding. To deselect a finding, click on the finding again.

- "Foods that contain tyramine might trigger my headaches." - "I will keep a food and headache diary." - "I will place a cool cloth on my forehead when I experience a migraine."

A nurse is caring for a client in the emergency department (ED). A nurse is caring for a client who has a migraine. Which of the following interventions should the nurse anticipate? Select all that apply.

- Administer sumatriptan. - Dim the lights in the client's room.

The nurse is caring for the client. The nurse is caring for the client 1 hr following chest tube insertion. Click to highlight the findings in the nurses' note that indicate the client's condition is improving. To deselect a finding, click on the finding again.

- Client reports pain as 3 on a scale of 0 to 10. - Client reports shortness of breath has decreased. - Wound dressing is dry and intact. - Respiratory rate 24/min. - Blood pressure 108/74 mm Hg. - Oxygen saturation 95% on 2 L/min via nasal cannula

A nurse is preparing to present a program about prevention of atherosclerosis at a health fair. Which of the following recommendations should the nurse plan to include? (Select all that apply.)

- Follow a smoking cessation program. - Maintain an appropriate weight. - Eat a low-fat diet.

A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions is the nurse's priority?

Apply firm pressure to the insertion site.

A nurse is caring for a client who is postoperative. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

- Hypovolemia - Initiate fluid challenge and insert a large-gauge IV. - Monitor blood pressure and urine output. The nurse should insert a large-gauge IV and initiate a fluid challenge because the client is most likely experiencing hypovolemia as evidenced by the client's restlessness, tachycardia, hypotension, decreased pulses, cool extremities, and decreased urine output. The nurse should monitor the client's urine output and blood pressure to evaluate the effectiveness of treatment.

A nurse is caring for a client who is postoperative following abdominal surgery. A nurse is caring for a client who is postoperative. Which of the following actions should the nurse take? Select all that apply.

- Instruct the client to splint the abdomen with a pillow for coughing. - Report urinary output to the provider. - Plan to ambulate the client as soon as possible. - Ask the client to rate their pain on a 0 to 10 pain scale.

A nurse is caring for a client who has a leg cast and is returning to demonstrate on the proper use of crutches while climbing stairs. Identify the sequence the client should follow when demonstrating crutch use. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

- Places body weight on the crutches. - Advances the unaffected leg onto the stair. - Shifts weight from the crutches to the unaffected leg. - Brings the crutches and the affected leg up to the stair.

A nurse is caring for a client in the emergency department (ED). Select the 4 findings that require follow-up by the nurse.

- Visual disturbances - Tingling of the lips - Hand grasps - Expressive aphasia

A nurse is teaching a class about client rights. Which of the following instructions should the nurse include?

A client should sign an informed consent before receiving a placebo during a research trial.

A nurse is evaluating the plan of care for four clients after 2 days of hospitalization. The nurse should identify the need to revise the plan for which of the following clients?

A client who is postoperative following abdominal surgery and reports feeling that something "popped" when they coughed.

A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate this risk, which of the following dietary alterations should the nurse recommend?

Add cabbage to the diet.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). A new bag is not available when the current infusion is nearly completed. Which of the following actions should the nurse take?

Administer dextrose 10% in water until the new bag arrives.

A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After ensuring a patent airway, which of the following nursing interventions is the priority?

Administering epinephrine

A nurse is admitting a client who has active tuberculosis. Which of the following types of transmission precautions should the nurse initiate?

Airborne

A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following nonpharmacological interventions should the nurse suggest to the client to reduce pain?

Alternate application of heat and cold to the affected joints.

The nurse is caring for the client. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client. (Client has a penetrating wound to the anterior upper right chest.)

Anticipated: - Prepare the client for chest tube insertion. - Transfuse packed RBCs. - Initiate NPO status. Contraindicated: - Place the client in Trendelenburg position. - Cover the client with a cooling blanket.

A nurse on a medical-surgical unit is reviewing the medical record of an older adult client who is receiving IV fluid therapy. Which of the following client information should indicate to the nurse that the client requires re-evaluation of the IV therapy prescription? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

BUN

A nurse is performing a dressing change for a client who is recovering from a hemicolectomy. When removing the dressing, the nurse notes that a large part of the bowel is protruding through the abdomen. Which of the following actions should the nurse take first?

Call for help.

A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the following actions should the nurse take first?

Check for the type and number of units of blood to administer.

A nurse in an emergency department is assessing an older adult client who has a fractured wrist following a fall. During the assessment, the client states, "Last week I crashed my car because my vision suddenly became blurry." Which of the following actions is the nurse's priority?

Check the client's neurologic status.

A nurse is planning care for a client who is postoperative following a laparotomy and has a closed-suction drain. Which of the following actions should the nurse take to manage the drain?

Compress the drain reservoir after emptying.

A nurse is caring for a client who has hypothyroidism. Which of the following manifestations should the nurse expect?

Constipation

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) and is NPO. When reviewing the chart, the nurse notes the following prescription: capillary blood glucose AC and HS. Which of the following actions should the nurse take?

Contact the provider to clarify the prescription.

A nurse is caring for a client who has increased intracranial pressure (ICP) and is receiving mannitol via continuous IV infusion. Which of the following findings should the nurse report to the provider as an adverse effect of this medication?

Crackles heard on auscultation

A nurse is providing preoperative teaching for a client who is scheduled for an open cholecystectomy. Which of the following actions should the nurse take?

Demonstrate ways to deep breathe and cough.

A nurse is caring for a client who is brought to the emergency department following an oil fire. Drag words from the choices below to fill in each blank in the following sentence.

During the emergent phase of burn care, the client is at risk for developing HYPOVOLEMIA and RESPIRATORY FAILURE.

A nurse is assessing a client who has had a suspected stroke. The nurse should place the priority on which of the following findings?

Dysphagia

A nurse is assessing a client who has advanced lung cancer and is receiving palliative care. The client has just undergone thoracentesis. The nurse should expect a reduction in which of the following common manifestations of advanced cancer?

Dyspnea

A nurse is caring for a client who is 4 hr postoperative following an open reduction internal fixation of the right ankle. Which of the following assessment findings should the nurse report to the provider?

Extremity cool upon palpation

A nurse is providing education to a client who has tuberculosis (TB) and their family. Which of the following information should the nurse include in the teaching?

Family members in the household should undergo TB testing.

A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the following instructions should the nurse include?

Flex the foot every hour when awake.

A nurse is caring for a client in the emergency department (ED). Drag one condition and one client finding to fill in each blank in the following sentence.

Following the administration of sumatriptan, the nurse should monitor for CHEST PAIN due to the risk of MYOCARDIAL ISCHEMIA.

A nurse is caring for a client who has DKA. Which of the following findings should indicate to the nurse that the client's condition is improving?

Glucose 272 mg/dL (74 to 106 mg/dL)

A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit?

Heart rate 110/min

A nurse is caring for a client has who has chronic glomerulonephritis with oliguria. Which of the following findings should the nurse identify as a manifestation of chronic glomerulonephritis?

Hyperkalemia

A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

Loosen restrictive clothing.

A nurse is creating a plan of care for a client who has neutropenia as a result of chemotherapy. Which of the following interventions should the nurse include in the plan?

Monitor the client's temperature every 4 hr.

A nurse is providing discharge teaching to a client who is postoperative following a modified radical mastectomy. Which of the following instructions should the nurse include?

Numbness can occur along the inside of the affected arm.

A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take first?

Obtain vital signs.

A nurse has received report on a client who is being admitted to the emergency department. Select the 3 findings that require follow-up by the nurse.

Oxygen saturation, pain level, wound drainage

A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the following results should the nurse expect?

PaCO2 56 mm Hg (35 to 45 mm Hg)

A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?

Place a pillow between the client's legs.

A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse take?

Place a pressure bag around the flush solution.

A nurse in a provider's office is assessing a client who has hypertension and takes propranolol. Which of the following findings should indicate to the nurse that the client is experiencing an adverse reaction to this medication?

Report of a night cough

A nurse is assessing a client following the completion of hemodialysis. Which of the following findings is the nurse's priority to report to the provider?

Restlessness

A nurse is assessing a client who has Graves' disease. Which of the following images should indicate to the nurse that the client has exophthalmos?

Select the picture with the eyes that appear to be bulging.

A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions should the nurse anticipate taking?

Slow the infusion rate.

A nurse is assessing a client who had extracorporeal shock wave lithotripsy (ESWL) 6 hr ago. Which of the following findings should the nurse expect?

Stone fragments in the urine

A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for omeprazole. The nurse should instruct the client that the medication provides relief by which of the following actions?

Suppressing gastric acid production

A nurse is planning care to decrease psychosocial health issues for a client who is starting dialysis treatments for chronic kidney disease. Which of the following interventions should the nurse include in the plan?

Tell the client that it is possible to return to similar previous levels of activity.

A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the nurse's priority?

Temperature 38.9° C (102° F)

A nurse is caring for a client who had a nephrostomy tube inserted 12 hr ago. Which of the following findings indicates a potential complication?

The client reports back pain.

A nurse is assessing a client while suctioning the client's tracheostomy tube. Which of the following findings should indicate to the nurse the client is experiencing hypoxia?

The client's heart rate increases.

A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following findings indicates that the client is experiencing a complication?

The client's surgical site dressing has required changing twice in 2 hr due to drainage.

The nurse is caring for the client. Drag words from the choices below to fill in each blank in the following sentence. (Client has a penetrating wound to the anterior upper right chest.)

The nurse should first address the client's OXYGENATION followed by the client's BLOOD PRESSURE.

A nurse is caring for a client in the emergency department (ED).

The nurse should identify that the client is most likely experiencing A MIGRAINE and the nurse should address the client's PAIN.

A nurse is caring for a client who is having a seizure. Which of the following interventions is the nurse's priority?

Turn the client to the side.

A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure injury. Which of the following actions should the nurse take?

Use a 30-mL syringe.

A nurse is providing teaching for a female client who has recurrent urinary tract infections. Which of the following information should the nurse include in the teaching?

Void before and after intercourse

A nurse is reviewing the laboratory results of a client who has a history of aplastic anemia. Which of the following findings indicates that the client is experiencing pancytopenia?

WBC count 2,000/mm3 (5000 to 10,000/mm3)

A nurse is planning care for a client who is undergoing brachytherapy via a sealed vaginal implant to treat endometrial cancer. Which of the following actions should the nurse include in the client's plan of care?

Wear a lead apron while providing care to the client.