ATI- PN Adult Medical Surgical Practice 2017 B

A nurse is reinforcing teaching with a client prior to removal of a leg cast. Which of the following statements should indicate to the nurse that the client understands the teaching?

"I will feel vibrations on my leg from the cast cutter."

A nurse is reinforcing discharge teaching with a client who has Crohn's disease. Which of the following statements should the nurse include in the teaching?

"Maintain a low-residue diet."

A nurse is collecting data from an older adult client who has several concerns. Which of the following concerns should the nurse recognize as a normal change associated with aging?

"My food tastes bland even after I add seasoning"

A nurse is caring for a client who has prostate cancer. The client asks the nurse why he is having difficulty with urination. Which of the following responses should the nurse make?

"The tumor causes obstruction of urine from the urethra."

A nurse is reinforcing discharge teaching with a client who has leukemia and is receiving chemotherapy. Which of the following statements should the nurse include in the teaching?

"You should place your toothbrush in hydrogen peroxide overnight."

A nurse is reinforcing teaching with a client about increasing dietary fiber. The nurse should recommend which of the following foods as the best source of fiber?

1/2 cup cooked kidney beans

A nurse is delegating the task of repositioning a client who is in skeletal traction to an assistive personnel (AP). Which of the following instructions should the nurse give the AP?

Allow the weights to hang freely.

A nurse is caring for a client who is suspected of having a myocardial infarction. Which of the following actions should the nurse take to prepare the client for an ECG?

Cleanse the client's skin prior to electrode placement.

A nurse is reinforcing teaching about nutrition choices with a client who has leukemia and is receiving chemotherapy. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching?

"I drink bottled water."

A nurse in a clinic is collecting data from a client who had hyperthyroidism and has been taking methimazole for 4 weeks. Which of the following statements bu the client indicates a therapeutic response of the medication?

"I have gained 3 pounds since my last appoint."

A nurse in a health clinic is reinforcing teaching with a client who has tuberculosis (TB) about transmission of the disease. Which of the following client statements indicates an understanding of the teaching?

"I inhaled the infected droplets that were in the air."

A nurse is reinforcing teaching with a client who has chronic kidney disease about disease management. Which of the following statements by the client indicates an understanding of the teaching?

"I will limit my daily intake of protein"

A nurse is reinforcing discharge teaching for a client who had a mechanical mitral valve replacement. Which of the following statements by the client indicates an understanding of the teaching?

"I will notify my dentist about this procedure."

A nurse is reinforcing teaching about pursed-lip breathing with a client who has a new diagnosis of COPD. The nurse should identify which of the following client statements indicates an understanding of the teaching?

"Pursed-lip breathing works best for activities like walking up stairs."

A nurse is reinforcing teaching with a client who is taking levothyroxine. Which of the following statements by the client indicates an understanding of the teaching?

"The medication should be taken before I eat breakfast every morning."

A nurse is caring for a client who begins to have a seizure while ambulating in the hall. Identify the sequence of actions the nurse should follow. (Move the steps the nurse should take into the box on the right, placing them in order of performance. Use all the steps.)

- Lower the client to the floor. - Place a pad beneath the client's head. - Loosen the clothing around the client's neck. - Time the length of the client's seizure. - Reorient and reassure the client.

A nurse is caring for a client who has an intestinal obstruction and reports a new onset of nausea. The client has an NG tube set as low intermittent suction and is receiving continuous IV infusion of 0.9% sodium chloride. Which of the following actions should the nurse take first?

Check for kinks in the NG tube

A nurse is caring for a client who is 2 hr postoperative following an amputation of the foot. Which of the following actions should the nurse take first?

Check the incisional dressing

A nurse is caring for a client who has a new cast on her left forearm and reports severe pain in the affected arm with numbness in the fingers. The nurse finds the skin is pale and cold with sluggish capillary refill. Which of the following fracture complications should the nurse suspect?

Compartment syndrome

A nurse is caring for a client who is postoperative and has a Jackson-Pratt drain. Which of the following actions should the nurse take?

Compress the bulb reservoir and then close the drainage valve.

A nurse is caring for a client who has been taking enalapril. The nurse should monitor the client for which of the following adverse effects?

Cough

A nurse is caring for four client. Which of the following conditions should the nurse identify as a risk for developing vascular disease?

Diabetes mellitus

A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following findings should the nurse report to the provider?

Diminished breath sounds.

A nurse is caring for an adult client who has age-related macular degeneration. Which of the following findings should the nurse expect?

Distorted central vision of the eyes.

A home health nurse is caring for a client who has COPD. The client tells the nurse that he becomes short of breath while eating despite the use of home oxygen. Which of the following instructions should the nurse include?

Drink beverages at the end of meals

A nurse is reinforcing teaching with a client who has circulatory compromise in the lower extremities due to peripheral vascular disease. Which of the following actions should the nurse take?

Educate the client about choosing low-fat, low-cholesterol foods

A nurse is reviewing the medical record of a client who has acute pancreatitis. Which of the following findings should the nurse anticipate?

Elevated serum amylase level.

A nurse is reviewing the laboratory reports of a client who reports chest pain. Which of the following laboratory results indicates the client is experiencing of myocardial infarction?

Elevated troponin

A nurse is assisting with the care of a client who had a stroke and is unable to speak. The nurse should identify that the client's injury occurred in which of the following lobes of the brain? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Frontal lobe

A nurse is reviewing the medication record of a client who is taking digoxin. Which of the following medications should the nurse identify as increasing the risk for the client to develop digoxin toxicity?

Furosimide

A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus about glycoslated hemoglobin (HbA1c) testing. Which of the following information should the nurse include in the teaching?

HbA1c results measure glucose control for the prior 3 months

A nurse is admitting a client who is suspected of having active tuberculosis (TB). Which of the following actions should the nurse take first?

Institute airborne precautions.

A nurse is caring for a client who is postoperative following a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigation. The nurse notes decreased output from the urethral catheter. Which of the following provider prescriptions should the nurse expect?

Irrigate the urethral catheter with 0.9% sodium chloride

A nurse is reviewing the plan of care for an older adult client who is 1 day postoperative following a total hip arthroplasty. Which of the following interventions should the nurse contribute to the plan of care?

Keep an abduction pillow between the client's legs

A nurse is caring for a client who has neutropenia. Which of the following nursing interventions should the nurse implement?

Limit visitors to healthy adults

A nurse is reinforcing teaching with the parent of a toddler who has type 1 diabetes mellitus and whose prescription has been changed from regular insulin to lispro insulin. Which of the following information should the nurse include in the teaching?

Lispro should be given before eating.

A nurse is caring for a client undergoing testing for multiple sclerosis. Which of the following findings should the nurse expect?

Muscle spasticity

A nurse is caring for a client following a thyroidectomy. Which of the following findings should alert the nurse to the possibility of parathyroid gland injury?

Muscle twitching

A nurse is preparing a client for a cardiac catheterization. Which of the following actions should the nurse take first?

Verify the client has given informed consent.

A nurse is contributing to the plan of care to promote a restful night's sleep for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

Offer a small snack at bedtime

A nurse is caring for a client who is 24 hr postoperative following an abdominal surgery. Which of the following findings requires immediate attention from the nurse?

Oxygen saturation of 88%

A nurse is caring for a client following a gastrectomy. Which of the following actions should the nurse take to decrease episodes of dumping syndrome?

Place the client in the supine position after meals.

A nurse is caring for a client who is in Buck's traction for a fractured hip. The client reports increased pain at the site of the fracture. Which of the following actions should the nurse take?

Reposition the client

A nurse is repositioning a client who has lower back pain. Which of the following positions is appropriate for the client?

Semi fowler's with knees flexed

A nurse in an orthopedic clinic is reinforcing teaching with a client who has osteoarthritis. Which of the following instructions should the nurse include to promote comfort?

Sleep on a firm mattress.

A nurse is contributing to the plan of care for a client who has a head injury and is at risk for increased intracranial pressure (ICP). Which of the following actions should the nurse include in the plan?

Use a turn sheet to reposition the client

A nurse is assisting in the plan of care for a client who had a recent left hemispheric stroke. Which of the following actions should the nurse include in the plan?

Use simple verbal cues when directing tasks.

A nurse is reviewing the medical record of a client who is postoperative. Which of the following findings should the nurse identify as a complication of surgery?

WBC count of 15,000/mm3

A nurse is reinforcing teaching with a client who has diabetes mellitus and a new prescription for regular NPH insulin. Which of the following instructions on preparing the insulin's should the nurse include?

Withdraw the regular insulin before withdrawing the NPH insuline

A nurse is caring for a client who has a prescription for digoxin 0.25 mg PO daily. While taking the client's apical pulse, the nurse notes a rate of 58/min. Which of the following actions should the nurse take?

Withhold the dose.