level 3 ATI Med surge
nurse is reinforcing teaching w/ a client who has peptic ulcer disease. which of the following instructions should the nurse include in the teaching?
eat a snack between meals
nurse is caring for a client who's receiving chemotherapy, the client mentions that she has a loss of appetite because she has sores in her mouth & that food no longer tastes good. which of the following suggestions by the nurse is appropriate?
eat several, small portioned meals daily
nurse is reinforcing teaching with a client who is to begin taking corticosterids. which of the following s/e of the medication should the nurse include in the teaching?
frequent colds
after receiving a change of shift report, which of the following older adult pt's should the nurse plan to visit first?
a pt who is dehydrated , has mental confusion, & was found getting out of bed several times during the night
nurse is reinforcing teaching about methods to reduce the possibilities of exacerbations w/ a client who has a new dx of MS. which of the following actions should the nurse reinforce?
avoid exposure to uppr respiratory infections
nurse is collecting data from a client who has hyperkalemia. which of the following findings should the nurse expect?
bradiacardia
nurse caring for a pt who has hypothyroidism. which of the following clinical manifestations should the nurse anticipate?
bradycardia
client who has a new dx of osteoporosis states to a nurse, I am lactose intolerant, so i cannot eat any dairy products. which of the following by the nurse is appropriate?
green leafy vegetables, such as spinach, kale, & collard greens are high in calcium
nurse in a clinic is caring for a client who has chronic kidney failure & is receiving epoetin alfa. which of the following lab values indicate the tx is effective?
hgb 11g/dl
nurse is reinforcing teaching w/ a newly licensed nurse on how to check a client for orthostatic hypotension. which of the following instructions should the nurse include?
wait at least 3 minutes to measure b/p after positioning changes
nurse is reinforcing a discharge teaching w/ a client who has MS. which of the following instructions should the nurse include?
plan to exercise daily
nurse is caring for a client who has type 2 diabetes mellitus. which of the following lab values indicate the client is at risk for delayed wound healing?
pre-albumin 12mg/dl
nurse is collecting data from a client who reports having nausea, vomiting & constipation for the last 48 hrs. which of the following questions should the nurse ask to help determine if the client is experiencing a bowel obstruction?
"for the can you describe the odor of your vomit?
nurse is caring for a client who is receiving continuous enteral feeding. which of the following actions should the nurse take? (all that apply)
*elevate the H.O.B to a 30 degree angle *auscultate for bowel sounds *change the tubing & feeding bag q24 hrs
a nurse is assisting w/ the admission of client who has c-diff. an AP asks the nurse about transmission-based precautions when caring for the pt. which of the following statements by the nurse are appropriate responses?
*provide the client w/ disposable utensils & dishes for meals *leave b/p equipment in the room *clean contaminated surfaces w/ a bleach solution
nurse is collecting data from a client who has c-diff & displays manifestations of dehydration. which of the following findings should the nurse expect? (all that apply)
*tenting of the skin *increased RR *urine output of 20ml/hr
nurse is caring for a client who is receiving digoxin for heart failure. which of the following findings should the nurse report to the provider as a possible indication of digoxin toxicity?
visual disturbances
nurse is reinforcing discharge teaching w/ a client who has esophageal varices. which of the following instructions should the nurse include?
consume foods high in fiber
nurse is contributing to the plan of care for a client who has peripheral arterial disease (PAD) of the lower extremities. which of the following interventions should the nurse include?
dangle the extremities off the side of the bed to reduce pain & swelling.
nurse caring for a pt who is receiving cyclosporine daily following an organ transplant. which indicates the pt is experiencing an s/e to the medication?
decreased urine output
nurse is reinforcing discharge instructions with a client who will be performing peritoneal dialysis at home. which of the following instructions should the nurse include in the teaching?
dialysate outflow should be clear in color
nurse collecting data from a 55 yr old female client who reports vaginal dryness & hot flashes. the client is interested in trying hormone replacement therapy (HRT). which of the following should the nurse recognize as a contraindication to HRT?
hx of tx for blood clots
nurse is reinforcing teaching w/ a female pt who had a pacemaker inserted 3 days ago. which statement by the pt indicates an understanding of the teaching?
i will avoid brushing my hair for 2 wks
A nurse is reinforcing discharge instructions to a client who is postoperative following fundoplication. Which of the following statements by the client indicates understanding of the teaching?
i will elevate the head of my bed on blocks
nurse caring for a client who has manifestations of sepsis.which of the following provider RX should the nurse implement first?
initiate 02 @ 4 L/min via nasal cannula
pt who had a transurethral resection of the prostate (TURP) has a normal saline continuous bladder irrigation in place. upon inspection of the indwelling urinary catheter & the drainage system, the nurse discovers that there is an internal obstruction of flow. what intervention is appropriate?
irrigate the catheter using a piston syringe
nurse caring for a client who ha PD & is taking carbidopa-levadopa, the client reports she can move well some days & other days has difficulty w/ ambulation. the nurse should suspect the client....
is developing a tolerance to the medication
nurse assisting w/ a plan of care for a pt who was admitted to the neurological unit following a stroke 3 hrs go. which of the following interventions is the priority?
keep the client in a side lying position
nurse is caring for a client who has retinal detachment at the inner aspect of his right eye. when preparing the client for surgery, the nurse should place him in which of the following positions?
left side-lying
nurse is reinforcing teaching with a client who has a left arm cast. which of the following instructions should the nurse include in the teaching to help promote mobility?
lift the arm over the head
A nurse is observing an assessment of a client who has GERD. Which of the following is an expected finding?
loss of tooth enamel
nurse is assisting w/ care of a client who was in a motor vehicle crash 4 hrs ago & has head injury. the nurse should place the client in which of the following positions?
low-fowler's
nurse is caring for a client who has a prescription for pneumatic compression devices for the lower extremities which of the following actions should the nurse take to ensure maximum benefit & proper management of the devices?
measure the circumference of the thighs
nurse is preparing to assist a pt out of bed 4hrs following a laparoscopic cholecystectomy. which of the following actions should the nurse take first?
obtain the pt's vital signs
nurse is caring for a client who is receiving tx for stage IV cancer. which of the following actions indicates the nurse is practicing the ethical principle of beneficence?
offering the client a PRN antiemetic prior to chemotherapy
nurse is planning to reinforce teaching w/ a pt who will be receiving noninvasive temporary pacing (NTP). which of the following statements should the nurse make to the pt?
pads will be placed on the left side of your chest and upper back
a client who has acute glomerulonephritis, what should the nurse expect?
periorbital edema
nurse is contributing to the plan of care for a client following an above the knee amputation. which of the following interventions should the nurse include?
place the client in prone position for 30 min 3 to 4 times per day
nurse in an urgent care clinic is caring for a client who has frostbite to the left foot. which of the following actions should the nurse take first?
place the clients foot in a water bath at 104 degrees Fahrenheit to prevent further damage of tissue
nurse caring for a client who's is experiencing an adrenal crisis. the crisis was precipitated by the client not taking her meds for several days. withdrawal from which of the following med is responsible for the client's condition?
prednisone
nurse in a long term care facility is leading an interprofessional team to review client care protocols. which of the following actions should the nurse take?
re-evaluate the teams progress during each meeting
nurse is reinforcing teaching with an older adult client who has osteoporosis, which of the following instructions should the nurse include in the teaching?
take calcium supplements 30 min before a meal
nurse is caring for a client who is receiving intermittent enteral feedings through an NG tube, which of the following actions should the nurse take?
test the PH of the gastric contents to verify tube placement
nurse is caring for a client who has Cushing's syndrome & expresses concern regarding body image changes. which of the following physical changes should the nurse recognize as a cause for this concern?
truncal obesity
nurse is reinforcing dietary teaching w/ a pt who has crohn's disease & a small bowel narrowing. which of the following foods should the nurse tell the pt to include in her diet?
turkey breast
nurse is collecting data from an older adult client & notices several skin lesions. the nurse should report the lesions to the provider if which of the following characteristics are noted?
variegated color & irregular borders
nurse is caring for client who has an NG tube. when giving a PO med, which of the following actions should the nurse take first?
verify tube placement