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ATI MED SURG COMPLETE SOLUTION PACKAGE
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ATI RN MED SURG PROCTORED EXAM; 100 QUESTIONS; VERIFIED Q & A
ATI RN MED SURG PROCTORED EXAM; 100 QUESTIONS; VERIFIED Q & A 1.A nurse is assessing a client who is 12hr postoperative following a colon resection. Whi... [Show More] ch of the following findings should the nurse report to the surgeon? 1. Heart rate 90/min 2. Absent bowel sounds → normal findings after major bowel surgery; takes several days to return to normal. 3. Hgb 8.2 g/dl 4. Gastric pH of 3.0 Rationale: Normal Hgb is 13-18M g/dl, 12-16 g/dl. This may indicate a possible hemorrhaging. 2. A nurse is caring for a client who has diabetes insipidus. Which of the following medications should the nurse plan to administer? a. Desmopressin b. Regular insulin c. Furosemide d. Lithium carbonate Rationale: Diabetes Insipidus has decreased ADH. Administer Desmopressin/Vasopressin increase ADH and keeps pt. on urinating 3. A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily for 3 years. Which of the following test should the nurse monitor? a. Fasting blood glucose b. Stool for occult blood c. Urine for white blood cells d. Serum calcium Rationale:ATI Pharm 16. Pg. 485 Ibuprofen (NSAIDs) monitor for GI bleed (bloody, tarry stools, abd pain). 4. A nurse in the emergency department is assessing a client. Which of the following actions should the nurse take first (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.) a. Obtain a sputum sample for culture b. Prepare the client for a chest x-ray c. Initiate airborne precautions d. Administer ondansertron. Rationale: No idea what the Exhibit is all about; wont be able to answer it. 5. A nurse is contacting the provider for a client who has cancer and is experiencing breakthrough pain. Which of the following prescriptions should the nurse anticipate? a. Transmucosal fentanyl b. Intramuscular meperidine c. Oral acetaminophen d. Intravenous dexamethasone Rationale:ATI pg. 27 6. A nurse is admitting a client who reports chest pain and has been placed on a telemetry monitor. Which of the following should the nurse analyze to determine whether the client is experiencing a myocardial infarction? a. PR interval b. QRS duration c. T wave d. ST segment Rationale: ST elevation indicates MI. ST depression indicates ischemia 7. A nurse is teaching a client who has ovarian cancer about skin care following radiation treatment. Which of the following instructions should the nurse include? a. Pat the skin on the radiation site to dry it b. Apply OTC moisturizer to the radiation site c. Cover the radiation site loosely with a gauze wrap before dressing d. Use a soft washcloth to clean the area around the radiation site Rationale: pg. 584. Dry the area thoroughly using patting motions. 8. A nurse is caring for a client who is receiving a blood transfusion. The nurse observes that the client has bounding peripheral pulses, hypertension, and distended jugular veins. The nurse should anticipate administering which of the following prescribed medications? a. Diphenhydramine b. Acetaminophen c. Pantoprazole d. Furosemide Rationale: S/S may indicate fluid retention or heart failure. It is important to administer diuretics to prevent cardiovascular/respiratory distress. 9. A nurse is assessing a client who is receiving magnesium sulfate IV for the treatment of hypomagnesemia. Which of the following findings indicates effectiveness of the medication? a. Lungs clear b. Apical pulse 82/min c. Hyperactive bowel sounds d. Blood pressure 90/50 mm Hg Rationale: ATI p. 494: s/s of hypomagnesemia consist of hypoactive bowel sounds, constipation, paralytic ileus. So effectiveness would indicate opposite of this 10. A nurse is reviewing a client’s ABG results pH 7.42, PaC02 30 mm Hg, and HCO3 21 mEq/L. The nurse should recognize these findings as indication of which of the following conditions? a. Metabolic acidosis b. Metabolic alkalosis c. Compensated respiratory alkalosis d. Uncompensated respiratory acidosis Rationale: because the HCO3 21 trying to compensate for respiratory alkalosis 11. A nurse is caring for a client who has a deep partial thickness burns over 15% of her body which of the following labs should the nurse expect during the first 24 hours A. Decreased BUN ELEVATED DT fluid loss B. Hypoglycemia (High due to stress) C. Hypoalbuminemia (Low due to fluid loss) D. Decreased Hematocrit (Elevated due to 3rd spacing during resuscitation phase) (Page 481 ch 75 med surge ati pdf 10.0) 12. A nurse is caring for a client who has dumping syndrome following a gastrectomy, which of the following actions should the nurse take ? a. Offer the client high carbohydrate meal options (High fat, high protein, low fiber, low to moderate carbs page 317, chapter 49 Peptic ulcer disease med surge ati pdf 10.0) b. Provide the client with four full meals a day (Small frequent meals) c. Encourage the client to to drink at least 360 ml of fluids with meals (Eliminate liquids with meals for 1 hr prior and following a meal) d. Have the client lie down for 30 minutes after meals (Lying down after a meal slows the movement of food within the intestines) 13. A nurse is teaching a group of young adult clients about risk factors for hearing loss. Which of the following factors should the nurse include in the teaching? SATA. (p.70 chapter 13) Born with a high weight Chronic infections of the middle ear Use a loop diuretic Perforation of the ear drum Frequent exposure to low volume noise [Show Less]
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ATI Med Surg Proctored Exam (Latest 2022 / 2023)
ATI Med Surg Proctored Exam (Latest 2022 / 2023) 1. A nurse is caring for a client who is receiving chemotherapy and requests information about acupunct... [Show More] ure to relieve some of the side effects. Which of the following findings should the nurse identify as a contraindication to receiving this alternative therapy? Lymphedema 2. A nurse is preparing to administer LR via continuous IV infusions at 200 mL/hr. The IV tubing has a drop factor of 10 drops/mL. How many gtt/min should the nurse set the IV pump to administer? 33 gtt/min 3. A nurse is providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following client statements indicates an understanding of the teaching? I should lie down when I take this medication 4. A nurse is providing discharge teaching to an older adult client following total hop arthroplasty. Which of the following instructions should the nurse include in the teaching? Install a raised toilet seat in your bathroom 5. A nurse is planning care for a client following cardiac catherization. Which of the following actions should the nurse take? Maintain the client’s affected extremity in extension 6. A nurse is caring for a client who has a lower extremity fracture and a prescription for crutches. Which of the following client statements indicates that the client is adapting to their roles change? I will need to have my partner take over shopping for groceries and cooking the meals for us 7. A nurse is providing teaching to a client who has an impaired immune system due to chemotherapy. Which of the following information should the nurse include in the teaching? Change your pet’s litter box daily 8. A nurse is caring for a client who has a contusion and reports thirst. The client’s urinary output was 4,000mL over the past 24hrs, the nurse should anticipate a prescription for which of the following IV medications? Desmopressin 9. A nurse in a clinic receives a phone call from a client who recently started therapy with an ACE inhibitor and reports nagging dry cough. Which of the following responses by the nurse is appropriate? Sucking on a lozenge may reduce the frequency of your cough 10. A nurse is taking an admission history from a client who reports Raynaud’s disease. Which of the following assessment findings should the nurse identify as a parenteral trigger for exacerbation of Raynaud’s? Using nicotine transdermal patch 11. A nurse is caring for a client who has a central venous device and notes the tubing has become disconnected, the client develops dyspnea and tachycardia. Which of the following actions should the nurse take first? On his left side in Trendelenburg position 12. A nurse is completing an assessment of an older client and notes reddened areas over the bony prominences, but the clients’ skin is intact. Which of the following interventions should the nurse include in the plan of care? Support bony prominences with pillows 13. A home health nurse is making an initial visit to a client who has multiple sclerosis. Which of the following actions is the priority for the nurse to take? List strategies for family coping when dealing with possible role changes 14. A nurse in the emergency department is assessing a client, which of the following actions should the nurse take first? Take airborne precautions 15. A nurse is reviewing the medial record of a client to identify factors for colorectal cancer. The nurse should identify which of the following findings as increasing the client’s risk? History of Crohn’s Disease 16. A nurse is caring for a client who is scheduling for a mastectomy. The client tells the nurse, “I’m not sure I want to have a mastectomy.” Which of the following statements should the nurse make? I can give you additional information about the procedure 17. A nurse is preparing to administer a unit of PRBCs to a client who is anemic. Identify the sequence of steps the nurse should follow Obtain venous access using an 18 gauge needle Obtain the unit of PRBCs from blood bank Verify blood compatibility with another nurse Initiate transfusion of the unit of PRBCs Remain with the client for the first 15-30 minutes [Show Less]
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ATI Med Surg Proctored Exam Question Bank; 134 Questions; 100% Verified Q & A
ATI Med Surg Proctored Exam Question Bank; 134 Questions; 100% Verified Q & A 1. A nurse is reinforcing teaching with a client who has HIV and is being di... [Show More] scharged to home. Which of the following instructions should the nurse include in the teaching? 1) Take temperature once a day. 2) Wash the armpits and genitals with a gentle cleanser daily. 3) Change the litter boxes while wearing gloves. 4) Wash dishes in warm water. 2. A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions? 1) Provide humidified oxygen. 2) Perform chest physiotherapy prior to suctioning. 3) Prelubricate the suction catheter tip with sterile saline when suctioning the airway.4) Hyperventilate the client with 100% oxygen before suctioning the airway.. 3. Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort? 1) Rub the client's feet briskly for several minutes. 2) Obtain a pair of slipper socks for the client. 3) Increase the client's oral fluid intake. 4) Place a moist heating pad under the client's feet. 4. A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for the nurse report to the provider? 1) Emesis of 100 mL 2) Oral temperature of 37.5° C (99.5° F) 3) Thick, red-colored urine 4) Pain level of 4 on a 0 to 10 rating scale 5. A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of the hypothermia blanket? 1) Shivering 2) Infection 3) Burns 4) Hypervolemia 6. A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? 1) "I will carry a complex carbohydrate snack with me when I exercise." 2) "I should exercise first thing in the morning before eating breakfast." 3) "I should avoid injecting insulin into my thigh if I am going to go running." 4) "I will not exercise if my urine is positive for ketones." 7. A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first? 1) Cover the client's wound with a moist, sterile dressing. 2) Have the client lie supine with knees flexed. 3) Check the client's vital signs. 4) Inform the client about the need to return to surgery. 8. A nurse is collecting data from a client who has alcohol use disorder and is experiencing metabolic acidosis. Which of the following manifestations should the nurse expect? 1) Cool, clammy skin. 2) Hyperventilation 3) Increased blood pressure 4) Bradycardia 9. A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching? 1) Avoid bending at the waist. 2) Remove the eye shield at bedtime. 3) Limit the use of laxatives if constipated. 4) Seeing flashes of light is an expected finding following extraction. 10.A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first? 1) Suggest that the client rests before eating the meal. 2) Request a dietary consult. 3) Check the client's vital signs. 4) Request an order for an antiemetic. 11.A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the client's wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found? 1) Sanguineous 2) Serous 3) Serosanguineous 4) Purulent 12.A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent postoperative complications which of the following actions should be reinforced during the teaching? [Show Less]
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ATI MED SURG PROCTORED EXAM (V2)- VERIFIED Q & A
ATI MED SURG PROCTORED EXAM (V2)- VERIFIED Q & A
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ATI RN Medical-Surgical Proctored Exam Correct questions and answers
ATI RN Medical-Surgical Proctored Exam 2019 Correct questions and answers 1. A nurse is caring for a client who is receiving chemotherapy and requests... [Show More] information about acupuncture to relieve some of the side effects. Which of the following findings should the nurse identify as a contraindication to receiving this alternative therapy? Lymphedema 2. A nurse is preparing to administer lactated Ringer's via continuous IV infusion at 200 ml/hr. The IV tubing has a drop factor of 10 drops/mL. How many gtt/min should the nurse set the IV ump to administer? 33 3. A nurse is providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following client statements indicates an understanding of the teaching? I should lie down when I take this medication 4. A nurse is providing discharge teaching to an older adult client following total hip arthroplasty. Which of the following instructions should the nurse include in the teaching? Install a raised toilet seat in your bathroom 5. A nurse is planning care for a client following a cardiac catheterization. Which of the following actions should the nurse take? Maintain the client's affected extremity in extension 6. A nurse is caring for a client who has a lower extremity fracture and a prescription for crutches. Which of the following client statements indicates that the client is adapting to their role change? I will need to have my partner take over shopping for groceries and cooking the meals for us 7. A nurse is providing teaching to a client who has an impaired immune system due to chemotherapy. Which of the following information should the nurse include in the teaching? wash peri area two times each day with antimicrobial soup 8. A nurse is caring for a client who has a contusion and reports thirst. The client's urinary output was 4,000 ml over past 24 hr. the nurse should anticipate a prescription for which of the following IV medications? Desmopressin 9. A nurse in a clinic receives a phone call from a client who recently started therapy with an ACE inhibitor and reports nagging dry cough. Which of the following responses by the nurse is appropriate? Sucking on a lozenge may reduce the frequency of your cough 10. A nurse is taking an admission history from a client who reports Raynaud's disease. Which of the following assessment findings should the nurse identify as a parenteral trigger for exacerbation of Raynaud's? Using nicotine transdermal patch 11. A nurse is caring for a client who has a central venous device and notes the tubing has become disconnected. the client develops dyspnea and tachycardia. Which of the following actions should the nurse take first? On his left side in Trendelenburg position 12. A nurse is completing an assessment of an older client and notes reddened areas over the bony prominences, but the client's skin is intact. Which of the following interventions should the nurse include in the plan of care? Support bony prominences with pillows 13. A home health nurse is making an initial visit to a client who has multiple sclerosis. Which of the following actions is the priority for the nurse to take? List strategies for family coping when dealing with possible role changes 14. A nurse in the emergency department is assessing a client. Which of the following actions should the nurse take first? (click on the "exhibit" button for additional information about the client) Initiate airborne precautions 15. A nurse is reviewing the medical record of a client to identify factors for colorectal cancer. The nurse should identify which of the following findings as increasing the client's risk? History of Crohn's disease 16. A nurse is caring for a client who is scheduled for a mastectomy. The client tells the nurse, "I'm not sure I want to have a mastectomy." Which of the following statements should the nurse make? I can give you additional information about the procedure 17. A nurse is preparing to administer a unit of packed RBCs to a client who is anemic. Identify the sequence of steps the nurse should follow. 1. obtain venous access using a 19-gauge needle 2. Obtain the unit of a packed RBCs from blood bank 3. verify blood compatibility with another nurse 4. Initiate transfusion of the unit of packed RBCs 5. Remain with the client for the first 15 to 30 minutes 18. A nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching? I should expect less than 25 ml of secretions per day in the drainage devices 19. A critical care nurse is assessing a client who has a severe head injury. In response to painful stimuli, the client does not open her eyes, displays decerebrate posturing and makes incomprehensible sounds. Which of the following Glasgow Coma scale scores should the nurse assign the client? 5 20. A nurse is providing discharge teaching to a client who has heart failure and instructs him to limit sodium intake to 2 g per day. Which of the following statements by the client indicates an understanding of the teaching? I can have a frozen fruit juice bar for dessert 21. A nurse is preparing to perform ocular irrigation for a client following a chemical splash to the eye. Which of the following actions should the nurse plan to take first? instill 0.9% sodium chloride solution into the affected eye 22. A nurse is assessing a client following extubation from a ventilator for which of the following findings should the nurse intervene immediately? Stridor 23. A nurse is reviewing the laboratory reports of a client who has acute pancreatitis. Which of the following findings should the nurse expect? Elevated blood glucose 24. A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of the following findings should the nurse expect? Urine specific gravity 1.001 25. A nurse is planning care for a client who has a pulmonary embolism. Which of the following interventions should the nurse include? Initiate a continuous IV heparin infusion 26. A nurse is providing discharge teaching to a client who is recovering from a sickle cell crisis. Which of the following instructions should the nurse include? Avoid extremely hot or cold temperatures 27. A nurse in the emergency department is caring for a client who is in hypovolemic shock. Which of the following actions should the nurse take first? Insert a large-bore IV catheter 28. A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation on of the graft? Palpable thrill [Show Less]
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RN Adult Medical Surgical ATI Proctored Exam ALL FORMS! - ACTUAL EXAMS (90 VERIRIED QUESTIONS).
RN Adult Medical Surgical ATI Proctored Exam ALL FORMS! - ACTUAL EXAMS (90 VERIRIED QUESTIONS).
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ATI Med-Surg proctored Exam (Latest Edition 2022-2023) 135 Verified Questions and Answers.
ATI Med-Surg proctored Exam Latest Edition 2022/2023 135 Verified Questions and Answers ATI Med-Surg proctored Exam (Latest Edition... [Show More] 2022/2023) 135 Verified Questions and Answers 1. A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching? 1) Take temperature once a day. 2) Wash the armpits and genitals with a gentle cleanser daily. 3) Change the litter boxes while wearing gloves. 4) Wash dishes in warm water. 2. A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions? 1) Provide humidified oxygen. 2) Perform chest physiotherapy prior to suctioning. 3) Prelubricate the suction catheter tip with sterile saline when suctioning the airway.4) Hyperventilate the client with 100% oxygen before suctioning the airway.. 3. Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort? 1) Rub the client's feet briskly for several minutes. 2) Obtain a pair of slipper socks for the client. 3) Increase the client's oral fluid intake. 4) Place a moist heating pad under the client's feet. 4. A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for the nurse report to the provider? 1) Emesis of 100 mL 2) Oral temperature of 37.5° C (99.5° F) 3) Thick, red-colored urine 4) Pain level of 4 on a 0 to 10 rating scale 5. A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of the hypothermia blanket? 1) Shivering 2) Infection 3) Burns 4) Hypervolemia 6. A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? 1) "I will carry a complex carbohydrate snack with me when I exercise." 2) "I should exercise first thing in the morning before eating breakfast." 3) "I should avoid injecting insulin into my thigh if I am going to go running." 4) "I will not exercise if my urine is positive for ketones." 7. A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first? 1) Cover the client's wound with a moist, sterile dressing. 2) Have the client lie supine with knees flexed. 3) Check the client's vital signs. 4) Inform the client about the need to return to surgery. 8. A nurse is collecting data from a client who has alcohol use disorder and is experiencing metabolic acidosis. Which of the following manifestations should the nurse expect? 1) Cool, clammy skin. 2) Hyperventilation 3) Increased blood pressure 4) Bradycardia 9. A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching? 1) Avoid bending at the waist. 2) Remove the eye shield at bedtime. 3) Limit the use of laxatives if constipated. 4) Seeing flashes of light is an expected finding following extraction. 10.A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first? 1) Suggest that the client rests before eating the meal. 2) Request a dietary consult. 3) Check the client's vital signs. 4) Request an order for an antiemetic. 11.A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the client's wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found? 1) Sanguineous 2) Serous 3) Serosanguineous 4) Purulent 12.A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent postoperative complications which of the following actions should be reinforced during the teaching? 1) Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises. 2) Place the client’s affected leg into the CPM machine with the machine in the flexed position. 3) Place the client into a high Fowler’s position when initiating the CPM exercises. 4) Align the joints of the CPM machine with the knee gatch in the client’s bed. 13.A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.) 1) Dyspnea 2) Barrel chest 3) Clubbing of the fingers 4) Shallow respirations 5) Bradycardia 14.A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client's right nostril. Which of the following actions should the nurse take first? 1) Take the client's temperature. 2) Place a dressing under the client's nose. 3) Notify the charge nurse. 4) Test the drainage for glucose. 15.A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia? 1) Monitor for elevated blood pressure. 2) Provide analgesia for headaches. 3) Prevent bladder distention. 4) Elevate the client's head. 16.A nurse is caring for a client who is being evaluated for endometrial cancer. Which of the following findings should the nurse expect the client to report? 1) Hot flashes 2) Recurrent urinary tract infections 3) Blood in the stool 4) Abnormal vaginal bleeding 17.A nurse is caring for a client following an open reduction and internal fixation of a fractured femur. Which of the following findings is the nurse's priority? 1) Altered level of consciousness 2) Oral temperature of 37.7° C (100° C) 3) Muscle spasms 4) Headache 18.A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge resection of the left lung and has a chest tube to suction. Which of the following is the priority finding the nurse should report to the provider? 1) Abdomen is distended 2) Chest tube drainage of 70 mL in the last hour 3) Subcutaneous emphysema is noted to the left chest wall 4) Pain level of 6 on a 0 to 10 scale 19.A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching? 1) Change the ostomy pouch daily. 2) Empty the ostomy pouch when it is 2/3 full. 3) Trim the opening of the ostomy seal to be 1/2 in. wider than the stoma. 4) Apply lotion to the peristomal skin when changing the ostomy pouch. 20.A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland. Which of the following actions should the nurse include in the plan? 1) Position the client supine while in bed. 2) Change the nasal drip pad as needed. 3) Encourage frequent brushing of teeth. 4) Encourage the client to cough every 2 hr following surgery. 21.A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily following a myocardial infarction. The nurse should instruct the client that aspirin is prescribed for clients who have coronary artery disease for which of the following effects? Which of the following findings should the nurse expect? 1) Loss o f peripheral vision 2) Headache 3) Halos around lights 4) Discomfort in the eyes 23.A nurse is collecting data from a client who has acute gastroenteritis. Which of the following data collection findings should the nurse identify as the priority? 1) Weight loss of 3% of total body weight. 2) Blood glucose 150 mg/dL. 3) Potassium 2.5 mEq/L 4) Urine specific gravity 1.035 24.A nurse is reinforcing discharge teaching with a client who had a total abdominal hysterectomy and a vaginal repair. Which of the following statements by the client indicates a need for further teaching? 1) "I should increase my intake of protein and vitamin C." 2) "I will no longer have menstrual periods." 3) "Once I am able to resume sexual activity, I can use a water-based lubricant if I experience discomfort." 4) "I will take a tub bath instead of a shower." 25.A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction. Which of the following actions should the nurse take? 1) Loosen the knots on the ropes if the client is experiencing pain. 2) Ensure the client’s weights are hanging freely from the bed. 3) Check the client’s bony prominences every 12 hr. 4) Cleanse the client’s pin sites with povidone-iodine. 26.A nurse in a provider’s office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include? 1) Take this medication between meals. 2) Limit intake of Vitamin C while taking this medication. 3) Take this medication with milk. 4) Limit intake of whole grains while taking this medication. 27.A nurse in a provider’s office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include? 1) Take this medication between meals. 2) Limit intake of Vitamin C while taking this medication. 3) Take this medication with milk. 4) Limit intake of whole grains while taking this medication. 28.A nurse is reviewing the plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse recommend? 1) Apply topical antifungal agents. 2) Apply fresh ice packs every 4 hr. 3) Wash daily with an antibacterial soap. 4) Keep draining lesions uncovered to air dry. 29.A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy established. Which of the following instructions should the nurse include in the teaching? 1) Empty the pouch immediately after meals. 2) Change the entire appliance once a day. 3) Limit fluid intake. 4) Avoid medications in capsule or enteric form. 30.A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for an escharotomy and wants to know what the procedure involves. Which of the following statements is appropriate for the nurse to make? 1) "An escharotomy surgically removes dead tissue." 2) "A cannula will be inserted into the bone to infuse fluids and antibiotics." 3) "A piece of skin will be removed and grafted over the burned area." 4) "Large incisions will be made in the burned tissue to improve circulation." 31.A nurse is collecting data from a client who has a possible cataract. Which of the following manifestations should the nurse expect the client to report? 1) Decreased color perception 2) Loss of peripheral vision 3) Bright flashes of light 4) Eyestrain 32.A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the following interventions should the nurse include in the plan of care? 1) Measure abdominal girth daily. 2) Use sterile water to irrigate the nasogastric tube.. 3) Maintain the client in Fowler’s position. 4) Moisten the client’s lips with lemon-glycerin swabs. 33.A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical manifestations should the nurse expect to observe? (Select all that apply.) 1) Baffalo hump 2) purple striations 3) moon face 4) Tremors 5) Obese extremities Buffalo hump Purple striations Moon face 34.A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following actions should the nurse take? 1) Provide a diet high in protein. 2) Provide ibuprofen for retroperitoneal discomfort. 3) intake and output hourly 4) Encourage the client to consume at least 2 L of fluid daily. 35.A nurse is reinforcing teaching about an esophagogastroduodenoscopy with a client who has upper gastric pain. Which of the following statements should the nurse include in the teaching? 1) "A flexible tube is introduced through the nose during the procedure." 2) "During the procedure you are in a sitting position." 3) "You will remain NPO for 8 hours before the procedure." 4) "You will be awake while the procedure is performed." 36.A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record? 1) Aura phase 2) Presence of automatisms 3) Postictal phase 4) Presence of absence seizures 37.A nurse is reinforcing teaching with a client who reports right shoulder pain following a laparoscopic cholecystectomy. Which of the following statements should the nurse make? 1) "The pain results from lying in one position too long during surgery." 2) "The pain occurs as a residual pain from cholecystitis." 3) "The pain will dissipate if you ambulate frequently." 4) "The pain is caused from the nitrous dioxide injected into the abdomen." 38.A nurse is checking the suction control chamber of a client's chest tube and notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? 1) Notify the provider. Answer Rationale: The nurse should check for kinks and take other measures before notifying the provider. 2) Verify that the suction regulator is on. 3) Continue to monitor the client because this is an expected finding. 4) Milk the chest tube to dislodge any clots in the tubing that may be occluding it. 39.A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.) 1) Encourage fluid intake 2) Monitor the puncture site for hematoma. 3) Insert a urinary catheter. 4) Elevate the client’s head of bed. 5) Apply a cervical collar to the client. 40.A nurse is assisting with the care of a client who is postoperative following surgical repair of a fractured mandible. The client’s jaw is wired shut to repair and stabilize the fracture. The nurse should recognize which of the following is the priority action? 1) Relieve the client's pain. 2) Check the client’s pressure points for redness. 3) Provide oral hygiene. 4) Prevent aspiration. 41.A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect? 1) A dry raised rash 2) Excessive salivation 3) Periorbital edema 4) Hardened skin 42.A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take? 1) Instruct the client to tilt her head back when she swallows. 2) Place food on the left side of the client's mouth. 3) Add thickener to fluids. 4) Serve food at room temperature. 43.A nurse is caring for a client who has partial-thickness and full-thickness burns of his head, neck, and chest. The nurse should recognize which of the following is the priority risk to the client? 1) Airway obstruction 2) Infection 3) Fluid imbalance 4) Contractures 44.A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis and is to start taking neostigmine. Which of the following instructions should the nurse include in the teaching? 1) Take the medication 45 minutes before eating. 2) Expect diaphoresis as a side effect of the neostigmine. 3) If a medication dose is missed, wait until the next scheduled dose to take the medication. 4) Treat nasal rhinitis with an over-the-counter antihistamine. 45.A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse notes there has not been any urinary output in the last hour. Which of the following actions should the nurse perform first? 1) Notify the provider. 2) Administer a prescribed analgesic. 3) Offer oral fluids. 4) Determine the patency of the tubing. 46.A nurse is caring for a client scheduled for a bone marrow biopsy. The client expresses fear about the procedure and asks the nurse if the biopsy will hurt. Which of the following responses should the nurse make? 1) "You must be very worried about what the biopsy will show." 2) "You'll be asleep for the whole biopsy procedure and won't be aware of what’s happening." 3) "Your provider scheduled this, so she will want to know you still have questions about the procedure." 4) "The biopsy can be uncomfortable, but we will try to keep you as comfortable as possible." 47.A nurse is assisting with planning care for a client who is recovering from a left-hemispheric stroke. Which of the following interventions should the nurse include in the plan? 1) Control impulsive behavior. 2) Compensate for left visual field deficits. 3) Re-establish communication. 4) Improve left-side motor function. 48.A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should monitor the client for which of the following manifestations? 1) Hypotension 2) Polyphagia 3) Hyperglycemia 4) Bradycardia 49.A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of 7/min. The arterial blood gas (ABG) values include: Oxygen saturation 80% pH 7.22 Bicarbonate 28 mEq/L PaCO2 68 mm Hg Base excess -2 PaO2 Which of the following interpretations 78 mm Hg of the ABG values should the nurse make 1) Metabolic acidosis 2) Respiratory acidosis 3) Metabolic alkalosis 4) Respiratory alkalosis 50.A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The nurse should recognize that which of the following statements by the client indicates a need for further teaching? 1) "I will avoid crossing my legs at the knees." 2) "I will use a thermometer to check the temperature of my bath water." 3) "I will not go barefoot." 4) "I will wear stockings with elastic tops." 51.A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease. The client becomes agitated and combative when the nurse approaches him. Which of the following actions should the nurse plan to take? 1) Turn the water on and ask the client to test the temperature. 2) Obtain assistance to place mitten restraints on the client. 3) Firmly tell the client that good hygiene is important. 4) Calmly ask the client if he would like to listen to some music. 52.A nurse is collecting data on a client’s wound. The nurse observes that the wound surface is covered with soft, red tissue that bleeds easily. The nurse should recognize this is a manifestation of which of the following? 1) Decreased perfusion 2) Infection 3) Granulation tissue 4) An inflammatory response 53.A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm3. Which of the following food items brought by the family should the nurse prohibit from being given to the client? 1) Baked chicken 2) Bagels 3) A factory-sealed box of chocolates 4 4) Fresh fruit basket 54.A nurse is contributing to the plan of care for an older adult client who is postoperative following a right hip arthroplasty. Which of the following interventions should the nurse include in the plan? 1) Perform the client's personal care activities for her. 2) Limit the client’s fluid intake. 3) Monitor the Homan’s sign. 4) Maintain abduction of the right hip. 55.A nurse is caring for a client who has heart failure and respiratory arrest. Which of the following actions should the nurse take first? 1) Establish IV access. 2) Feel for a carotid pulse. 3) Establish an open airway. 4) Auscultate for breath sounds. 56.A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longer certain he wants to have the procedure. Which of the following responses should the nurse make? 1) "Why have you changed your mind about the surgery?" 2) "Bypass surgery must be very frightening for you." 3) "Your provider would not have scheduled the surgery unless you needed it." 4) "I will call your doctor and have him discuss your surgery with you." 57.A nurse is caring for a client who is postoperative following foot surgery and is not to bear weight on the operative foot. The nurse enters the room to discover the client hopped on one foot to the bathroom, using an IV pole for support. Which of the following actions should the nurse take? 1) Walk the client back to bed immediately and get the client a bedpan. 2) Tell the client to remain in the bathroom after toileting and obtain a wheelchair. 3) Warn the client she might have to be restrained if she gets up without assistance. 4) Keep the bathroom door open to ensure the client is okay. 58.A nurse is assisting with the care of a client who is postoperative and has a closed-wound drainage system in place. Which of the following actions should the nurse take? 1) Fully recollapse the reservoir after emptying it. 2) Empty the reservoir once per day. 3) Replace the drainage plug after releasing hand pressure on the device. 4) Irrigate the tubing with sterile normal saline solution at least once every 8 hr. 59.A nurse is reinforcing discharge instructions with a client who has hepatitis A. Which of the following statements by the client indicates an understanding of the teaching? 1) "I will not eat fried foods." 2) "I will abstain from sexual intercourse." 3) "I will refrain from international travel." 4) "I will not order a salad in a restaurant." 60.A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching? 1) Rest in a supine position. 2) Consume a low-protein diet. 3) Breathe in through her nose and out through pursed lips. 4) Limit fluid intake throughout the day. 61.A nurse is caring for a client who is postoperative and has a history Addison's disease. For which of the following manifestations should the nurse monitor? 1) Hypernatremia 2) Hypotension 3) Bradycardia 4) Hypokalemia 62.A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is to take hydroxyzine preoperatively. Which of the following effects of the medication should the nurse include in the teaching? (Select all that apply.) 1) Decreasing anxiety 2) Controlling emesis 3) Relaxing skeletal muscles 4) Preventing surgical site infections 5) cing the amount of narcotics needed for pain relief 63.A nurse is reinforcing teaching with a client who has a new prescription for epoetin alfa. The nurse should reinforce to the client to take which of the following dietary supplements with this medication? 1) Vitamin D 2) Vitamin A 3) Iron 4) Niacin 64.A nurse is caring for a client after a radical neck dissection. To which of the following should the nurse give priority in the immediate postoperative period? 1) Malnourishment related to NPO status and dysphagia 2) Impaired verbal communication related to the tracheostomy 3) High risk for infection related to surgical incisions 4) Ineffective airway clearance related to thick, copious secretions 65.A nurse is contributing to the plan of care for a client who has a spinal cord injury at level C8 who is admitted for comprehensive rehabilitation. Which of the following long-term goals is appropriate with regard to the client's mobility? 1) Walk with leg braces and crutches. 2) Drive an electric wheelchair with a hand-control device. 3) Drive an electric wheelchair equipped with a chin-control device. 4) Propel a wheelchair equipped with knobs on the wheels. 66.A nurse is reinforcing health teaching about skin cancer with a group of clients. Which of the following risk factors should the nurse identify as the leading cause of non-melanoma skin cancer? 1) Exposure to environmental pollutants 2) Sun exposure. 3) History of viral illness 4) Scars from a severe burn : 67.Based on a client's recent history, a nurse suspects that a client is beginning menopause. Which of the following questions should the nurse ask the client to help confirm the client is experiencing manifestations of menopause? 1) "Do you sleep well at night?" 2) "Have you been experiencing chills?" 3) "Have you experienced increased hair growth?" 4) "When did you begin your menses?" 68.A nurse is reinforcing teaching with a client about cancer prevention and plans to address the importance of foods high in antioxidants. Which of the following foods should the nurse include in the teaching? 1) Cottage cheese 2) Fresh berries 3) Bran cereal 4) Skim milk 69.A nurse is assisting with caring for a client who has a new concussion following a motor-vehicle crash. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? 1) Polyuria 2) Battle's sign 3) Nuchal rigidity 4) Lethargy 70.A nurse is reinforcing teaching about a tonometry examination with a client who has manifestations of glaucoma. Which of the following statements should the nurse include in the teaching? 1) "Tonometry is performed to evaluate peripheral vision." 2) "This test will diagnose the type of your glaucoma." 3) "Tonometry will allow inspection of the optic disc for signs of degeneration." 4) "This test will measure the intraocular pressure of the eye." 71.A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a kidney transplant. Which of the following laboratory findings should the nurse identify as the most important to report to the provider? Increase in serum glucose 2) Increase in serum creatinine 3) Decrease in white blood cell count 4) Decrease in platelets 72. A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect? 1) Apical pulse rate different than the radial pulse rate 2) Increase in heart rate by 20% when standing 3) Drop in systolic BP by 20 mm Hg when moving from a lying to a sitting position 4) Drop in systolic BP more than 10 mm Hg on inspiration 73.A nurse is caring for a client who has Alzheimer's disease. The nurse discovers the client entering the room of another client, who becomes upset and frightened. Which of the following actions should the nurse take? 1) Attempt to determine what the client was looking for. 2) Explain the client’s Alzheimer’s diagnosis to the frightened client. 3) Reprimand the client for invading the other client's privacy. 4) Ask the client to apologize for his behavior. 74.A nurse is caring for a client immediately following a cardiac catheterization with a femoral artery approach. Which of the following actions should the nurse take? 1) Check pedal pulses every 15 min. 2) Perform passive range-of-motion for the affected extremity. 3) Remind the client not to turn from side to side. 4) Keep the client in high-Fowler's position for 6 hr. 75.A nurse is assisting with planning an immunization clinic for older adult clients. Which of the following information should the nurse plan to include about influenza? 1) Individuals at high risk should receive the live influenza vaccine. 2) Immunization for influenza should be repeated every 10 years. 3) The composition of the influenza vaccine changes yearly. 4) The influenza vaccine is necessary only for clients who have never had influenza. 76.A nurse is caring for an older adult client who has colon cancer. The client asks the nurse several questions about his treatment plan. Which of the following actions should the nurse take? 1) Tell the client to have a family member call the provider to ask what options he plans to recommend. 2) Assure the client that the provider will tell him what is planned. 3) Help the client write down questions to ask his provider. 4) Provide the client with a pamphlet of information about cancer. 77.A nurse is caring for a client who has hemiplegia following a stroke. The client's adult son is distressed over his mother's crying and condition. Which of the following responses should the nurse make? 1) "If you just sit quietly with your mother, I'm sure she will calm down." 2) "I'll talk with your mother and see if I can comfort her." 3) " It must be hard to see your mother so ill and upset." 4) "Your mother's crying seems to bother you more than it does her." 78.A nurse is reinforcing teaching with the family of a client who has primary dementia. Which of the following manifestations of dementia should the nurse include in the teaching? 1) Temporary, reversible loss of brain function 2) Forgetfulness gradually progressing to disorientation 3) Sleeping more during the day than nighttime 4) Hyper vigilant behaviors 79.A nurse is contributing to the plan of care for a client who has labyrinthitis. Which of the following interventions should the nurse include in the plan? 1) Limit fluid intake.. 2) Monitor client’s cardinal fields of vision. 3) Encourage ambulation. 4) Ensure the room is brightly lit. 80.A nurse is contributing to the plan of care for a client who is admitted with a deep vein thrombosis (DVT) of the left leg. Which of the following interventions should the nurse include in the plan? 1) Apply ice to the extremity 2) Monitor platelet levels 3) Restrict oral fluids 4) Administer vasodilating medications 81.A nurse is caring for a client who comes to the clinic to be tested for tuberculosis (TB) after a close family contact tests positive. Which of the following measures should the nurse anticipate preparing for this client? 1) Tuberculin skin test 2) Sputum culture for acid fast bacillus (AFB) 3) Bacille Calmette-Guérin (bCG) vaccine 4) Chest x-ray 82.A nurse is reviewing data for a client who has a head injury. Which of the following findings should indicate to the nurse that the client might have diabetes insipidus? 1) Serum sodium 145 mEq/L 2) Urine specific gravity 1.028 3) Urine output 650 mL/hr 4) Blood glucose 198 mg/dL 83.A nurse is caring for a client who has recurrent kidney stones and a history of diabetes mellitus. The client is scheduled for an intravenous pyelogram (IVP). The nurse should collect additional data about which of the following statements made by the client? 1) "I took a laxative yesterday." 2) "I took my metformin before breakfast." 3) "I haven't had anything to eat or drink since last night." 4) "The last time I voided it was painful." 84.A nurse is collecting data from a client who is having an acute asthma exacerbation. When auscultating the client's chest, the nurse should expect to hear which of the following sounds? 1) Expiratory wheeze 2) Pleural friction rub 3) Fine rales 4) Rhonchi 85.A nurse is planning to change an abdominal dressing for a client who has an incision with a drain. Which of the following actions should the nurse plan to take? 1) Remove the entire dressing at once. 2) Loosen the dressing by pulling the tape away from the wound. 3) Don clean gloves to remove the dressing. 4) Open sterile supplies before removing the dressing. 86.A nurse is caring for a client who is scheduled to undergo thoracentesis. In which of the following positions should the nurse place the client for the procedure? 1) Prone with arms raised over the head. 2) Sitting, leaning forward over the bedside table. 3) High Fowler’s position 4) Side-lying with knees drawn up to the chest. 87.A nurse is caring for a client newly diagnosed with ovarian cancer. Which of the following reactions from the client should the nurse initially expect? 1) Denial 2) Bargaining 3) Acceptance 4) Anger 88.A nurse is contributing to the plan of care for a client who is postoperative following peritoneal lavage for peritonitis. The client has a nasogastric tube to low-intermittent suction and closed- suction drains in place. Which of the following interventions should the nurse include in the plan? 1) Irrigate the nasogastric tube with tap water. 2) Mark abdominal girth once daily. 3) Ambulate the client twice daily. 4) Place the client in a high Fowler’s position. 89.A nurse is caring for a client who is receiving hemodialysis. Which of the following client measurements should the nurse compare before and after dialysis treatment to determine fluid losses? 1) Neck vein distention 2) Blood pressure 3) Body weight 4) Abdominal girth 90.A nurse is caring for a client who is receiving a unit of packed RBCs. About 15 min following the start of the transfusion, the nurse notes that the client is flushed and febrile, and reports chills To help confirm that the client is having an acute hemolytic transfusion reaction, the nurse should observe for which of the following manifestations? 1) Urticaria 2) Muscle pain 3) Hypotension 4) Distended neck veins 91.A nurse is caring for a client who has a seizure disorder and reports experiencing an aura. The nurse should recognize the client is experiencing which of the following conditions? 1) A continuous seizure state in which seizures occur in rapid succession 2) A sensory warning that a seizure is imminent 3) A period of sleepiness following the seizure during which arousal is difficult 4) A brief loss of consciousness accompanied by staring 92.A nurse is caring for a client who just had cataract surgery. Which of the following comments from the client should the nurse report to the provider? 1) "The bright light in this room is really bothering me." 2) "My eye really itches, but I'm trying not to rub it." 3) "It's really hard to see with a patch on one eye." 4) "I need something for the horrible pain in my eye." 93.A nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if there will be a lot of pain during the procedure. Which of the following responses should the nurse make? 1) "You shouldn't feel any pain since the local area is anesthetized." 2) "Most clients report more discomfort from the preparation than from the procedure itself." 3) "You may feel some cramping during the procedure." 4) "Don't worry; you won't remember anything about the procedure due to the effects of the medication." 94.A nurse caring for a client at risk for increased intracranial pressure is monitoring the client for manifestations that indicate that the pressure is increasing. To do this, the nurse should check the function of the third cranial nerve by performing which of the following data-collection activities? 1) Observing for facial asymmetry 2) Checking pupillary responses to light 3) Eliciting the gag reflex 4) Testing visual acuity 95.A nurse is caring for a client during the immediate postoperative period following thoracic surgery. When administering an opioid analgesic for pain, the nurse should explain that the medication should have which of the following effects? 1) Reducing anxiety 2) Increasing blood pressure 3) Increasing coughing 4) Increasing the client's respiratory rate 96.A nurse is collecting data on a client who has hyperthyroidism. Which of the following manifestations should the nurse expect the client to report? 1) Frequent mood changes 97.A nurse is collecting data from a client who has skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites? 98 .A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The nurse determines that teaching has been effective when the client identifies which of the following manifestations of hypoglycemia? (Select all that apply.) 101.A nurse is caring for a client who is experiencing an acute exacerbation of ulcerative colitis. The nurse should recognize that which of the following actions is the priority? 1) Review stress factors that can cause disease exacerbation. 2) Evaluate fluid and electrolyte levels. 3) Provide emotional support. 4) Promote physical mobility. 102. A nurse is reinforcing teaching about rifampin with a female client who has active tuberculosis. Which of the following statements should the nurse include in the teaching? 1) "You should wear glasses instead of contacts while taking this medication." 2) "The medication causes amenorrhea if taken along with an oral contraceptive." 3) "A yellow tint to the skin is an expected reaction to the medication." 4) "Lifelong treatment with this medication is necessary." 103.A nurse is reinforcing teaching about cyclosporine for a client who is postoperative following a renal transplant. Which of the following statements by the client indicates an understanding of the teaching? 1) "I will take this medication until my BUN returns to normal." 2) "This medication will help my new kidney make adequate urine." 3) "I will need to take this medication for the rest of my life." 4) "This medication will boost my immune system." 104.A nurse is caring for a client who has Parkinson's disease and is taking selegiline 5 mg by mouth twice daily. Which of the following therapeutic outcomes should the nurse monitor for with a client who is taking this medication? 1) Improved speech patterns 2) Increased bladder function. 3) Decreased tremors 4) Diminished drooling 105.A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood cells. The client develops itching and hives. Which of the following actions should the nurse take first? 1) Obtain vital signs. 2) Stop the transfusion. 3) Notify the registered nurse. 4) Administer diphenhydramine. 106.A nurse is reinforcing teaching with a client about how to prevent the onset of manifestations of Raynaud’s phenomenon. Which of the following statements should the nurse identify as an indication that the client needs further teaching? 1) "I will keep my house at a cool temperature." 2) "I will try to anticipate and avoid stressful situations." 3) "I will complete the smoking cessation program I started." 4) "I will wear gloves when removing food from the freezer." 107.A nurse is reinforcing teaching with a client who has iron deficiency anemia and is to start taking ferrous sulfate twice a day. Which of the following statements by the client indicate an understanding of the teaching? 1) "I will take the medication with orange juice." 2) "I should expect to have loose stools while taking this medication." 3) "I will have clay colored stools while taking this medication." 4) "I should take the medication with milk." 108.A nurse is reinforcing teaching about pernicious anemia with a client following a total gastrectomy. Which of the following dietary supplements should the nurse include in the teaching as the treatment for pernicious anemia? 1) Vitamin B12 2) Vitamin C 3) Iron 4) Folate 109.A nurse is caring for a client who is scheduled for surgical repair of a femur fracture and has a prescription for lorazepam preoperatively. Which of the following statements by the client should indicate to the nurse that the medication has been effective? 1) "My mouth is very dry." 2) "I feel very sleepy." 3) "I am not hungry any longer." 4) "My leg feels numb." 110.A nurse is collecting data from a client who has AIDS. When checking the client's mouth, the nurse notes a white, creamy covering on the tongue and buccal membranes. The nurse should recognize this is a manifestation of which of the following conditions? 1) Xerostomia 2) Gingivitis 3) Candidiasis 4) Halitosis 111.A nurse is caring for a client who is postoperative open reduction and internal fixation with placement of a wound drain to repair a hip fracture. Which of the following actions should the nurse take? 1) Empty the suction device every 4 hr. 2) Monitor circulation on the affected extremity every 2 hr for the first 12 hr. 3) Position the client’s hip so that it is internally rotated. 4) Encourage foot exercises every 4 hr. 112.A nurse is assisting with teaching a client who has a history of smoking about recognizing early manifestations of laryngeal cancer. The nurse should instruct the client to monitor and report which of the following manifestations of laryngeal cancer? 1) Aphagia 2) Hoarseness 3) Tinnitus 4) Epistaxis 113.A nurse is collecting data from a client who has systemic lupus erythematosus (SLE). Which of the following laboratory values should the nurse review to determine the client’s renal function? 1) Antinuclear antibody 2) C-reactive protein 3) Erythrocyte sedimentation rate 4) Serum creatinine 115. A nurse is collecting data from a client who has Cushing's syndrome. Which of the following manifestations should the nurse expect? 1) Bruising 2) Weight loss 3) Hyperpigmentation 4) Double vision 116. A nurse is caring for a client who is postoperative and requesting something to drink. The nurse reads the client's postoperative prescriptions, which include, "Clear liquids, advance diet as tolerated." Which of the following actions should the nurse take first? 1) Offer the client apple juice. 2) Elevate the client’s head of bed. 3) Auscultate the client’s abdomen. 4) Order a lunch tray for the client. 117. A nurse is collecting data on a client who has a surgical wound healing by secondary intention. Which of the following findings should the nurse report to the charge nurse? 1) The wound is tender to touch. 2) The wound has pink, shiny tissue with a granular appearance. 3) The wound has serosanguineous drainage. 4) The wound has a halo of erythema on the surrounding skin. 118. A nurse is assisting with the care of a client who has multiple injuries following a motor vehicle crash. The nurse should monitor for which of the following manifestations of a pneumothorax? 1) Inspiratory stridor 2) Expiratory wheeze 3) Absence of breath sounds 4) Coarse crackles 119. A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect? 1) Frothy sputum 2) Dyspnea 3) Orthopnea 4) Peripheral edema 120. A nurse is caring for a client who is receiving chemotherapy for treatment of ovarian cancer and experiencing nausea. Which of the following actions should the nurse take? 1) Advise the client to lie down after meals. 2) Instruct the client to restrict food intake prior to treatment. 3) Provide the client with an antiemetic 2 hr prior to the chemotherapy. 4) Encourage the client to drink a carbonated beverage 1 hr before meals. 121. A nurse is assisting with the care of a client following a transurethral resection of the prostate (TURP) and has an indwelling urinary catheter. Which of the following actions should the nurse take? 1) Weigh the client weekly. 2) Irrigate the catheter as prescribed. 3) Instruct the client to report an urge to urinate. 4) Instruct the client to bear down as if to have a bowel movement every hour. 122. A nurse is evaluating discharge instructions for a client following a right cataract extraction. Which of the following client statements indicates the teaching is effective? 1) "I will take a stool softener until my eye is healed." 2) "I will expect to have moderately severe pain for 1-2 days." 3) "I will refrain from cooking for 1 week." 4) "I will bend at the waist to tie my shoes." 123. A nurse is collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? 1) Decreased pedal pulses 2) Hypertension 3) Peripheral edema 4) Diarrhea 124. A nurse is caring for a client who has COPD. Which of the following actions should the nurse take? 1) drink 8 glasses of water a day. 2) Instruct the client to cough every 4 hr. 3) Provide the client with a low protein diet. 4) Advise the client to lie down after eating. 125. A nurse is caring for a client who was admitted with major burns to the head, neck, and chest. Which of the following complications should the nurse identify as the greatest risk to the client? 1) Hypothermia 2) Hyponatremia 3) Fluid imbalance 4) Airway obstruction 126. A nurse is collecting data from a client who was bitten by a tick one week ago. Which of the following client manifestations should the nurse identify as an indication of the development of Lyme disease? 1) An expanding circular rash 2) Swollen, painful joints 3) Decreased level of consciousness 4) Necrosis at the site of the bite 127. A nurse is contribution to the plan of care for a client who is 12 hr postoperative following a right radical mastectomy with closed suction drains present. The nurse should expect that the client will be unable to perform which of the following activities with her right arm? 1) Combing her hair 2) Eating her breakfast 3) Buttoning her blouse 4) Tying her shoes 128. A nurse in a provider’s office is collecting data for a 45-year-old client who is having manifestations associated with perimenopause. Which of the following findings should the nurse expect? 1) Report of urinary retention 2) Elevated blood pressure above 140/90 3) Report of dryness with vaginal intercourse 4) Elevated body temperature above 37.8° C (100° F) 129. A nurse is reinforcing teaching about breast self-examination (BSE) with a client who has a regular menstrual cycle. The nurse should instruct the client to perform BSE at which of the following times? 1) On the same day every month 2) Prior to the beginning of menses 3) Three to seven days after menses stops 4) On the second day of menstruation 130. A nurse is caring for a client who has second- and third-degree burns and a prescription for a high-calorie, high-protein diet. Which of the following menu choices should the nurse recommend? 1) 1⁄2 cup whole-grain pasta with tomato sauce and pears 2) Turkey and cheese sandwich with scalloped potatoes 3) 1⁄2 cup black beans with a brownie 4) Roast beef with romaine lettuce salad 131. A nurse is reinforcing teaching to a client who is scheduled for an intravenous pyelogram. Which of the following should the nurse include in the teaching? 1) Omit your daily dose of aspirin. 2) Take a laxative the evening before the procedure. 3) Expect to be drowsy for 24 hr following the procedure. 4) You will feel cold chills after the dye has been injected. 132. A nurse is collecting data from a client in the health clinic who is reporting epigastric pain. Which of the following statements made by the client should the nurse identify as being consistent with peptic ulcer disease? 1) "The pain is worse after I eat a meal high in fat." 2) "My pain is relieved by having a bowel movement." 3) "I feel so much better after eating." 4) "The pain radiates down to my lower back." 133. A nurse is contributing to the plan of care for a client who has a terminal illness. Which of the following interventions should the nurse identify as the priority? 1) Promote the client’s expression of feelings about loss of self-care ability. 2) Encourage the client to recall positive life events. 3) Schedule pain medication on a routine basis. 4) Suggest ways the client can continue interacting with social contacts. 134. A nurse is reinforcing teaching with a client who has been newly diagnosed with chronic open angle glaucoma. Which of the following statements by the client indicates an understanding of the teaching? 1) "When my vision improves, I will be able to stop taking the eye drops." 2) "If I forget to take my eye drops, I should wait until the next time they are due." 3) "I should call the clinic before taking any over-the-counter medications." 4) "Every two years I will need to have my vision checked by an eye doctor." [Show Less]
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ATI MED SURG PROCTORED EXAM 2022 2023 –STUDY GUIDE 100 Verified Questions & Answers.
ATI MED SURG PROCTORED EXAM 2022/2023 STUDY GUIDE 100 Verified Questions & Answers ATI MED SURG PROCTORED EXAM 2022/2023 –STUDY GUIDE / 100 Questio... [Show More] ns & Answers A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of the following findings should the nurse identify as a manifestation of this condition? A. Bounding pedal pulse B. Capillary refill less than 2 seconds C. Pain that increases with passive movement D. Areas of warmth on the cast C. Pain that increases with passive movement A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Which of the following statements made by the client reflects an understanding of the teaching? A. "I will need to take antibiotics for 1 year" B. "My partner will need to take an antiviral medication" C. "My joints ache because I have Lyme disease" D. "I will bruise easily because I have Lyme disease" C. "My joints ache because I have Lyme disease" A nurse is preparing to administer phenytoin 600 mg PO daily to a client. The amount available is oral solution 125 mg/5 mL. How many mL should the nurse administer?24 A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse take? A. Flush the line before administering antibiotics B. Position the client in Trendelenburg to obtain measurements C. Have the client bear down when readings are obtained D. Place a pressure bag around the flush solution D. Place a pressure bag around the flush solution A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of the following findings should the nurse identify as the priority? A. Report of sore throat B. Report of memory loss C. Alopecia D. Mucositis A. Report of sore throat A nurse is reviewing the medical record of a client who has systemic lupus erthematosus (SLE). Which of the following findings should the nurse expect? A. Facial butterfly rash B. Bradycardia C. Esophagitis D. Interstitial fibrosis A. Facial butterfly rash A nurse is planning care for a client who is postoperative following a parathyroidectomy. Which of the following actions should the nurse identify as the priority? A. Use pillows to support the client's head and neck B. Offer opioid medication C. Place a tracheostomy tray at the bedside D. Place the client in semi-Fowler's position C. Place a tracheostomy tray at the bedside A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect? A. Low urine specific gravity B. Hypertension C. Bounding peripheral pulses D. Hyperglycemia A. Low urine specific gravity 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? A. "You will have an implant placed twice each month for the duration of the treatment" B. "You should remain at least 6 feet away from others between treatments" C. "You should expect to have blood in your urine for a few days after treatment" D. "You will need to stay still in the bed during each treatment session" D. "You will need to stay still in the bed during each treatment session" 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? A. Encourage the client to take deep breaths after the procedure B. Assist the client to hold their arms up during the procedure C. Instruct the client to remain NPO after midnight prior to the procedure D. Keep the client on bedrest for 8 hr following the procedure A. Encourage the client to take deep breaths after the procedure 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? A. Administer an antihistamine B. Slow the infusion rate C. Give the client a corticosteriod D. Elevate the client's lower extremities B. Slow the infusion rate A nurse is providing teaching to a client who has end-stage kidney disease and is waiting for a kidney transplant. Which of the following information should the nurse provide? A. Kidney donation must come from a living donor B. Immunosuppressive therapy is necessary until the donated kidney begins producing urine C. Hemodialysis is sometimes required following surgery D. Kidney transplant recipients can resume their regular diet following surgery C. Hemodialysis is sometimes required following surgery A nurse is caring for a client who has hypothyroidism. Which of the following manifestations should the nurse expect? A. Constipation B. Insomnia C. Tachycardia D. Diaphoresis A. Constipation A nurse is providing preoperative teaching for a client who is scheduled for a mastectomy. Which of the following statements should the nurse make? A. "You should accept your body image change before discharge" B. "It is important for you to look at the incisional site when the dressings are removed" C. "I will refer you to community resources that can provide support" D. "The scar will remain red and raised for many years after surgery" C. "I will refer you to community resources that can provide support" A nurse is caring for a client who had a nephrostomy tube inserted 12 hr ago. Which of the following findings should the nurse report to the provider? A. The client's urinary output has increased B. The client reports back pain C. The client's urine color is red tinged D. The client's BUN is 18 mg/dL B. The client reports back pain A nurse is teaching a family about the care of a patient who has a new diagnosis of Alzheimer's disease. Which of the following information should the nurse include in the teaching? A. Position tabletop clocks with multi-colored backgrounds throughout the home B. Explain how to complete a task while having the client do the task C. Place a calendar on the wall with days and weeks included D. Create complete outfits and allow the client to select one each day D. Create complete outfits and allow the client to select one each day A nurse is caring for a client who has breast cancer and tells the nurse that they would like to have acupunture because it provides greater relief than pain medication. Which of the following statements should the nurse make? A. "Acupuncture is not an approved treatment for cancer pain" B. "I can speak to the provider about incorporating acupuncture into your treatment plan" C. "I will ask the provider to prescribe a stronger medication to help ease your pain" D. "I can contact a family member or spiritual advisor for you to speak with" B. "I can speak to the provider about incorporating acupuncture into your treatment plan" A nurse is caring for a client following extubation of an edotracheal tube 10 min ago. Which of the following findings should the nurse report to the provider immediately? A. Stridor B. Oral secretions C. Hoarseness D. Sore throat A. Stridor A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr ago. The nurse should identify which of the following findings as an indication of a myocardial infarction (MI)? A. Creatine kinase (CK-MB) 85 mg/dL B. High-density lipoprotein (HDL) 65 mg/dL C. Alanine aminotransferase (ALT) 28 units/L D. Troponin I 8 ng/mL D. Troponin I 8 ng/mL 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? A. Obtain the client's vital signs B. Describe the blood transfusion procedure to the client C. Check for the type and number of units of blood to administer D. Initiate a peripheral IV line C. Check for the type and number of units of blood to administer A nurse is reviewing the laboratory results of a client who has aplastic anemia. Which of the following findings indicates a potential complication? A. RBC count 5.2 million/mm^3 B. WBC count 2,000/mm^3 C. Platelets 380,000/mm^3 D. Potassium 4 mEq/L B. WBC count 2,000/mm^3 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? A. Flex the affected arm when ambulating B. Numbness can occur along the inside of the affected arm C. Begin active range-of-motion exercises 1 day after surgery D. Dress in clothing that fits snugly B. Numbness can occur along the inside of the affected arm A nurse is preparing to present a program about prevention of atherosclerosis at a health far. Which of the following recommendations should the nurse plan to include? (Select all that apply.) A. Follow a smoking cessation program B. Maintain an appropriate weight C. Eat a low-fat diet D. Increase fluid intake E. Decrease intake of complex carbohydrates A, B, C 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? A. "Wear an eye patch over one eye" B. "Make sure to have a staff member walk on your stronger side" C. "Scan the environment by turning your head from side to side" D. "Make sure to look at your feet while walking" C. "Scan the environment by turning your head from side to side" A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the following findings is an indication of lung re-expansion? A. The chest tube is draining serosanguineous fluid at 65 mL/hr B. The client tolerates gentle milking of the tubing C. Bubbling in the water seal chamber has ceased D. There is tidaling in the water seal chamber C. Bubbling in the water seal chamber has ceased A nurse is providing discharge teaching to a client who is to self-administer heparin subcutaneously. Which of the following statements by the client indicates an understanding of the teaching? A. "I can expect to have blood in my urine during the first week of injections" B. "I will floss my teeth after each meal" C. "I will gently massage the site after I inject my medication" D. "I will use an electric razor to shave" D. "I will use an electric razor to shave" A nurse is providing follow-up care for a client who is sustained a compound fracture 3 weeks ago. The nurse should recognize that an unexpected finding for which of the following laboratory values is a manifestation of osteomyelitis and should be reported to the provider? A. Sedimentation rate B. Hematocrit C. Calcium D. Acid phosphatase A. Sedimentation rate A nurse is performing a preoperative assessment for a client. The nurse should identify that an allergy to which of the following foods can indicate a latex allergy? A. Shellfish B. Peanuts C. Avocados D. Eggs C. Avocados 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? A. Potassium 3.5 mEq/L B. pH 7.28 C. Glucose 272 mg/dL D. HCO3 14 mEq/L C. Glucose 272 mg/dL A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following should the nurse plan to administer? A. 240 mL (8oz) of orange juice B. 1 ampule of 50% dextrose IV bolus C. NPH insulin 60 units subcutaneous D. Regular insulin 20 units IV bolus D. Regular insulin 20 units IV bolus 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. A client who is taking potassium supplements, has a potassium level of 3.2 mEq/L and reportsconstipation B. A client who has Alzeimer's Disease (AD), has a room near the nurse's station, and is agitated C. A client who is postoperative following abdominal surgery and reports feeling that something "popped" when they coughed D. A client who has a conductive hearing loss, speaks softly, and is scheduled for a cerumen removal C. A client who is postoperative following abdominal surgery and reports feeling that something "popped" when they coughed A nurse is providing teaching to a client who has a new prescription for psyllium. Which of the following information should the nurse include in the teaching? A. Drink 240 mL (8 oz) of water after administration B. Expect results in 4 to 6 hr C. Take this medication before meals to increase appetite D. Reduce dietary fiber intake to improve medication absorption A. Drink 240 mL (8 oz) of water after administration 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? A. "I will wear a badge to measure how much radiation I am receiving" B. "I will remove the markings on my skin after each radiation treatment" C. "I will avoid direct exposure to the sun" D. "I will rinse my mouth with a commercial mouthwash" C. "I will avoid direct exposure to the sun" A nurse is admitting a client who has active tuberculosis. Which of the following types of transmission precautions should the nurse initiate? A. Airborne B. Droplet C. Contact D. Protective environment A. Airborne A nurse is reviewing the medical record of a client who has osteomyelitis and a prescription for gentamicin. Which of the following findings from the client's medical record should indicate to the nurse the need to withhold the medication and notify the provider? A. WBC count B. Temperature C. Blood pressure D. Serum creatinine D. Serum creatinine A nurse is providing teaching to a client who is perimenopausal and has a prescription for hormone replacement therapy. For which of the following adverse effects should the nurse instruct the client to notify the provider? (Select all that apply.) A. Night sweats B. Calf pain C. Vaginal dryness D. Numbness in the arms E. Intense headache B, D, E A nurse is planning discharge teaching for a client who has an external fixation device for a fracture of the lower extremity. Which of the following instructions should the nurse include in the plan of care? A. Secure the straps firmly around the boot B. Remove the device before showering C. Use crutches with rubber tips D. Adjust the screws to maintain alignment C. Use crutches with rubber tips 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? A. "Older adult clients might require up to 6 grams of acetaminophen over 24 hours for effective pain control" B. "Ibuprofen can cause gastrointestinal bleeding in older adult clients" C. "Meperidine is the medication of choice for older adult clients experiencing severe pain"D. "Older adult clients taking oxycodone are at risk for diarrhea" B. "Ibuprofen can cause gastrointestinal bleeding in older adult clients" A nurse is caring for a client who has a cervical spinal cord injury sustained 1 month ago. Which of the following manifestations indicates that the client is experiencing autonomic dysreflexia (AD)? A. Temperature 38.9 C (102 F) B. Systolic blood pressure 70 mm Hg C. Heart rate 52/min D. Respiratory rate 8/min C. Heart rate 52/min 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? A. Dyspnea B. Hemoptysis C. Mucus production D. Dysphagia A. Dyspnea 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? A. "Ginkgo biloba relieves nausea for people who have vertigo" B. "Taking ginkgo biloba will help relieve your joint pain" C. "Ginko biloba can cause an increased risk for bleeding" D. "Taking ginkgo biloba decreases the risk of migraine headache" C. "Ginko biloba can cause an increased risk for bleeding" 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? A. Blood pressure B. Prescribed medications C. Oxygen saturation D. BUN D. BUN A nurse is obtaining a medication history from a client who is scheduled to undergo cataract surgery. The nurse should recognize that which of the following client medications is a contradiction for the surgery and notify the provider? A. Hydrocondone B. Bupropion C. Lactulose D. Warfarin D. Warfarin A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect? A. Painless ulcerations on the ankles B. Hair loss on the lower legs C. No extremity pain when resting D. Rubor with elevation of the extremity B. Hair loss on the lower legs A home health nurse is providing teaching to a client who has a stage 1 pressure injury on the greater trochanter of his left hip. Which of the following instructions should the nurse include in the teaching? A. Clean the wound daily with an antiseptic B. Use a donut-shaped pillow when sitting in a chair C. Change positions every hour D. Massage the area two times daily C. Change positions every hour 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? A. Increase intake of foods containing calcium B. Alternate application of heat and cold to the affected joints C. Keep the affected extremities elevated D. Limit movement of the affected joints B. Alternate application of heat and cold to the affected joints 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? A. Temperature 37.2 C (99 F) B. Blood pressure 100/70 mmHg C. Weight loss D. Restlessness D. Restlessness 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? A. Extremity cool upon palpation B. Serosanguineous drainage on the dressing C. Capillary refill of 2 seconds D. Client report of discomfort when moving toes A. Extremity cool upon palpation A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the nurse's priority? A. Moderate serosanguinous drainage on the dressing B. Calcium 9.5 mg/dL C. Temperature 38.9 C (102 F) D. Decreased bowel sounds C. Temperature 38.9 C (102 F) A nurse is planning care for a client who is having a modified radical mastectomy of the right breast. Which of the following interventions should the nurse include in the plan of care? A. Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24 hr period B. Assist the client to start arm exercises 48 hr after surgery C. Maintain the right arm in an extended position at the client's side when in bed D. Place the client in a supine position for the first 24 hr after surgery A. Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24 hr period A nurse is teaching a client about the use of transcutaneous electrical nerve stimulation (TENS) for the management of bone cancer pain. The nurse should explain that applying a TENS unit to the painful area has which of the following effects? A. Electrically generated feelings of heat B. Cryotherapy for painful areas C. A tingling sensation replacing the pain D. Realignment of energy flow through meridians C. A tingling sensation replacing the pain A nurse is providing teaching to a client who has a recent diagnosis of constipation-predominant irritable bowel syndrome. Which of the following instructions should the nurse include in the teaching? A. Take a calcium antacid before meals and at bedtime B. Consume at least 30 g of fiber daily C. Take a stimulant laxative daily D. Consume no more than 1,000 mL of water per day B. Consume at least 30 g of fiber daily A nurse is providing teaching to a client who has AIDS. Which of the following statements by the client indicated an understanding of the teaching? A. "I should clean my toothbrush in the dishwasher once a month" B. "I should eat more fresh fruits and vegetables" C. "I will avoid drinking a glass of cold liquid that has been standing for 30 minutes D. "I will take my temperature once a day" D. "I will take my temperature once a day" A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation. Which of the following values should the nurse identify as a desired outcome for this therapy? A. INR 1 B. INR 2.5 C. aPTT 45 seconds D. aPTT 90 seconds B. INR 2.5 A nurse is caring for a newly admitted client who has a gastric hemorrhage and is going into shock. Identify the sequence of actions the nurse should take 1. Administer oxygen via a nonrebreather 2. Initiate IV therapy with a large-bore catheter 3. Insert an NG tube 4. Adminster ranitidine A nurse is assessing heart sounds of a client who reports substernal precordial pain. Identify which of the following sounds the nurse should document in the client's medical record by listening to the audio clip. A. Murmur B. S4 C. Pericardial friction rub D. Ventricular gallop C. Pericardial friction rub A nurse is teaching a client about osteoporosis prevention. The nurse should instruct the client that which of the following medications can increase their risk for developing osteoporosis? A. Conjugated estrogens B. Enalapril C. Prednisone D. Colchicine C. Prednisone A nurse is providing education to a client who is at risk fro osteoporosis. Which of the following instructions should the nurse include? A. Begin taking glucosamine supplements B. Walk for 30 mins four times per week C. Jog for 15 mins two times per week D. Avoid taking over-the-counter calcium supplements B. Walk for 30 mins four times per week A nurse is teaching a client who has a cardiac dysrhythmia about the purpose of undergoing continuous telemetry monitoring. Which of the following statements by the client reflects an understanding of the teaching? A. "This measures how much blood my heart is pumping" B. "This identifies if I have a defective heart valve" C. "This identifies if the pacemaker cells of my heart are working properly" D. "This measures the blood circulating to my heart muscle" C. "This identifies if the pacemaker cells of my heart are working properly" A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The client is unable to void on the bedpan. Which of the following actions should the nurse take first? A. Document the client's intake and output B. Scan the bladder with a portable ultrasound C. Pour warm water over the client's perineum D. Perform a straight catheterization B. Scan the bladder with a portable ultrasound 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? A. The client starts to cough B. The client's heart rate increases C. The client is diaphoretic D The client's blood pressure decreases B. The client's heart rate increases A nurse is providing discharge instructions to a client who has active tuberculosis (TB). Which of the following information should the nurse include in the instructions? A. Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures B. The contagious period generally lasts for 6 to 8 weeks after the initiation of medication therapy C. Family members should follow airborne precautions at home D. A follow-up tuberculosis skin test is necessary in 2 months A. Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The client's inital vital signs were HR 80, BP 130/70, R 16, and temp 96.8. Which of the following vital sign changes should alert the nurse that the client might be hemorrhaging? A. Heart rate 110 B. BP 160/70 C. R 14 D. Temp 101.1A. Heart rate 110 A nurse is caring for a client who has a positive culture for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take? A. Obtain a sputum specimen to determine if there is colonization B. Bathe the client using chlorhexidine solution C. Place the client in droplet isolation D. Restrict visits from the client's friends and familyB. Bathe the client using chlorhexidine solution A nurse is assessing a client's hydration status. Which of the following findings indicates fluid volume overload? A. Warm, moist skin B. Distended neck veins C. Dark amber, odiferous urine D. Orthostatic hypotension B. Distended neck veins A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the following instructions should the nurse include? A. Flex the foot every hour when awake B. Place a pillow under the knee when lying in bed C. Lower the leg when sitting in a chair D. Ensure the leg is abducted when resting in bed A. Flex the foot every hour when awake 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? A. Applying oxygen via face mask B. Placing the client in Fowler's position C. Administering epinephrine D. Initiating an IV infusion of 0.9% sodium chloride A. Applying oxygen via face mask 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? A. Check the client's neurologic status B. Document the client's statements C. Prepare the client for a CT scan D. Teach the client about using safety precautions for falls A. Check the client's neurologic status A nurse is caring for an older adult client who has dementia and requires acute care for a respiratory infection. The client is agitated and is attempting to remove their IV catheter. Which of the following actions should nurse take to avoid restraining the client? A. Check on the client every 2 hr B. Provide a quiet environment with no distractions C. Turn on the television in the client's room D. Keep the client occupied with a manual activity D. Keep the client occupied with a manual activity 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? A. "Discontinuing the treatments is your choice if it is your wish to do so." B. "Your daughter is named as your health care surrogate. I will ask her if you can stop them" C. "I will call your spiritual advisor to come in, so you can discuss this with them"D. "Next time you have an oncology appointment, you should as the oncologist" A. "Discontinuing the treatments is your choice if it is your wish to do so." A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? A. Explain procedures as they occur to the client B. Place personal items, such as pictures, at the client's bedside C. Orient the client to their location once a shift D. Encourage the family members to remain home until the client has adjusted B. Place personal items, such as pictures, at the client's bedside A nurse is providing teaching to a client who has asthma about the use of a metered-dose inhaler. The nurse should identify that which of the following client actions indicates an understanding of the teaching? A. Breathing in rapidly while administering the medication B. Washing the plastic case and cap of the inhaler in the dishwasher C. Holding breath for 10 seconds after inhaling D. Waiting 15 seconds between puffs, if two puffs are required C. Holding breath for 10 seconds after inhaling A nurse is administering packed RBCs to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction? A. Anorexia and jaundice B. Bronchospasm and urticaria C. Hypertension and bounding pulse D. Low back pain and apprehension D. Low back pain and apprehension A nurse is caring for a client who is having a tonic-clonic seizure while in bed and has become cyanotic. Which of the following actions should the nurse take? (Select all that apply.) A. Restrain the client B. Prepare to suction the client's airway C. Insert a tongue blade in the client's mouth D. Raise the head of the client's bed to a semi-Fowler's position E. Loosen restrictive clothing on the client B, E 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? A. Decreased heart rate B. Crackles heard on auscultation C. Increased urinary output D. Decreased deep tendon reflexes B. Crackles heard on auscultation A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron supplement. Which of the following statements by the client indicates an understanding of the teaching? A. "I will take my iron with a glass of milk" B. "I will take an antacid with my iron" C. "I will limit my intake of red meat" D. "I will eat more high-fiber foods" D. "I will eat more high-fiber foods" A nurse is providing discharge teaching about infection prevention to a client who has AIDS. Which of the following statements by the client indicates understanding of the teaching? A. "I will eat a salad at least once each day to increase my intake of vitamin K" B. "I can work in my flower garden as long as I wear gardening gloves to cover my skin" C. "I will no longer floss my teeth after brushing my teeth" D. "I can sip on a glass of juice for at least 2 hours before I should discard it" C. "I will no longer floss my teeth after brushing my teeth" A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and notes clots in the client's indwelling urinary catheter and a decrease in urinary output. Which of the following actions should the nurse take? A. Remove the client's indwelling urinary catheter B. Irrigate the indwelling urinary catheter C. Clamp the indwelling urinary catheter D. Apply traction to the indwelling urinary catheter B. Irrigate the indwelling urinary catheter A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following information should the nurse include in the teaching? A. "Take this medication on an empty stomach" B. "Eczema is an immediate expected adverse effect of this medication" C. "Increase fiber intake to avoid constipation" D. "Monitor your blood pressure monthly" C. "Increase fiber intake to avoid constipation" A nurse is checking the ECG rhythm strip for a client who has a temporary pacemaker. The nurse notes a pacemaker artifact followed by a QRS complex. Which of the following actions should the nurse take? A. Document that depolarization has occurred B. Increase the pacemaker's voltage C. Decrease the pacemaker's sensitivity D. Check the placement of the ECG leads A. Document that depolarization has occurred A nurse is caring for a client who is receiving total paretneral 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? A. Check the client's blood glucose according to facility mealtimes B. Contact the provider to clarify the prescription C. Request for meals to be provided for the client D. Hold the prescription until the client is no longer NPO B. Contact the provider to clarify the prescription A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube. The nurse should recognize that which of the following complications is associated with longterm mechanical ventilation? A. Elevated blood pressure B. Dehydration C. Stress ulcers D. Hypernatremia C. Stress ulcers A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the following results should the nurse expect? A. PaCO2 56 mm Hg B. pH 7.38 C. HCO3 24 mEq/L D. PaO2 90 mm Hg A. PaCO2 56 mm Hg 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? A. After 1 week of medication, TB is no longer communicable B. Dispose of contaminated tissues in a paper bag C. Airborne precautions are necessary in the home D. Family members in the household should undergo TB testing D. Family members in the household should undergo TB testing A nurse is planning for a client who is postoperative following a laparotomy and has a closedsuction drain. Which of the following actions should the nurse take to manage the drain? A. Set the wall suction to 80 to 100 mm Hg B. Compress the drain reservoir after emptying C. Allow the drainage to collect on a sterile gauze dressing D. Position the drain below the bed to promote drainage B. Compress the drain reservoir after emptying A nurse is planning care for a client who has a sealed radiation implant for cervical cancer. Which of the following interventions should the nurse include in the plan of care? A. Keep a lead-lined container in the client's room B. Limit each visitor to 1 hr per day C. Place a dosimeter badge on the client D. Remove soiled linens from the client's room each day A. Keep a lead-lined container in the client's room A nurse is reviewing the laboratory results of a client who has AIDS and is taking amphotericin B for a fungal infection. The nurse should identify that which of the following values is an indication of an adverse effect of the medication? A. Potassium 4.8 mEq/L B. Magnesium 1.7 mEq/L C. BUN 34 mg/dL D. Hematocrit 45% C. BUN 34 mg/dL A nurse is planning a health promotional presentation for a group of African American clients at a community center. Which of the following disorders presents the greatest risk to this group of clients? A. Multiple sclerosis B. Skin cancer C. Urolithiasis D. Hypertension D. Hypertension [Show Less]
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ATI med surg retake Exam 2022-2023 (GRADED A+) Questions and Answers 100- Verified
A nurse is caring for a client who is 24 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take? Maintai... [Show More] n abduction of the affected extremity. A nurse is providing teaching to a client who is scheduled for a bronchoscopy. Which of the following statements should the nurse include in the teaching? "You will not be able to eat or drink after the procedure until you are able to cough." A nurse is assessing a client's understanding of a surgical procedure prior to witnessing their signature on the informed consent form. The nurse determines that the client does not understand what the procedure will involve. Which of the following actions should the nurse take? Contact the provider who will be performing the procedure. A nurse is providing discharge teaching to a client who has COPD. Which of the following instructions should the nurse include in the teaching? "Consume a diet that is high in calories." The nurse should instruct the client to avoid foods that are gas forming, such as cauliflower and cabbage. These foods can increase the client's abdominal discomfort. "Select desserts such as angel-food cake." A nurse is monitoring a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a manifestation of Cushing's triad? Increase in blood pressure from 130/80 mm Hg to 180/100 mm Hg A nurse is teaching a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? "I am aware that my diabetes is caused by an autoimmune disorder." A nurse is caring for a client who has a small bowel obstruction and an NG tube in place. Which of the following actions should the nurse take? Maintain low intermittent suction. A nurse is assessing a client who has a chest tube connected to a closed water-seal drainage system. Which of the following findings should the nurse report to the provider? Constant bubbling in the water seal chamber A nurse is providing teaching for a client who has neutropenia and is receiving chemotherapy. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.) "I will avoid crowds "I will take my temperature daily A nurse is preparing to administer propranolol to several clients. For which of the following clients should the nurse clarify the prescription with the provider before administration? A client who has a history of asthma A nurse is analyzing the ABG results of a client who is in respiratory acidosis. Which of the following mechanisms should the nurse identify as responsible for this acid-base imbalance? Retention of carbon dioxide A nurse is planning care for a client who has tuberculosis. Which of the following precautions should the nurse implement for this client? Airborne precautions A nurse is caring for a client who is 3 hr postoperative and exhibiting signs of hypovolemia. Which of the following findings should the nurse identify as a manifestation of hypovolemia? Rapid pulse rate A nurse is caring for a client who has a prescription for lactated Ringer's by continuous IV infusion to replace output from an NG tube. Which of the following findings should indicate to the nurse that this therapy is effective? Urine specific gravity 1.020 A nurse in an emergency department is caring for a client who is confused, has a temperature of 40° C (104° F), a BP of 74/52 mm Hg, and a diagnosis of exertional heat stroke. Which of the following actions should the nurse take first? Administer oxygen using a high-concentration mask. A nurse is providing teaching to a client about strategies to manage menopausal symptoms. Which of the following instructions should the nurse include in the teaching? "Use water-based lubricant during intercourse to reduce discomfort." A nurse is teaching a client about self-management of their halo fixator device. Which of the following information should the nurse include in the teaching? Place a small pillow under the head while lying supine. A home health nurse is inspecting a client's residence for electrical hazards as part of the agency's quality improvement plan. Which of the following findings should the nurse identify as a safety hazard? An IV pump is plugged into an outlet near a sink. A nurse is providing teaching to a group of clients about the prevention of coronary artery disease. Which of the following information should the nurse include in the teaching? Walk 30 min daily at a comfortable pace. A nurse is performing a risk assessment for a client. Which of the following factors should the nurse identify as increasing the client's risk for falls? The client had cataract surgery 1 day ago. A nurse is planning care for a client who is receiving intermittent IV fluids via a peripherally inserted central catheter (PICC). Which of the following information should the nurse include in the client's plan of care? Assess the PICC infusion system systematically. A nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions should the nurse implement to decrease the client's risk for ventilator-associated pneumonia (VAP)? (Select all that apply.) Monitor for oral secretions every 2 hr. Provide oral care every 2 hr. Assess the client daily for readiness of extubation. A nurse is providing teaching for a client who has constipation-predominant irritable bowel syndrome (IBS-C). Which of the following statements should the nurse include in the teaching? "Take psyllium in the evening." A nurse is planning care for a client who has a lump in their right breast. Which of the following findings increases the client's risk of developing breast cancer? Oral contraceptives were taken for the last 6 years A nurse is assessing a client who has an exacerbation of diverticular disease. In which of the following quadrants should the nurse anticipate the client to be experiencing abdominal pain? Left lower quadrant A nurse is providing teaching to a client who has a new prescription for levothyroxine to treat hypothyroidism. Which of the following statements by the client indicates an understanding of the teaching? "If my heart starts racing, my provider might need to adjust my dosage." A nurse is providing preoperative teaching about stool consistency to a client who will undergo a colectomy with the placement of an ileostomy. Which of the following information about stool consistency should the nurse include in the teaching? The stool will have a high volume of liquid. A nurse is planning care for a client who is scheduled for surgery and has a latex allergy. Which of the following actions should the nurse plan to take? Place monitoring cords and tubes in a stockinette. A nurse is assessing a client who has a central venous catheter (CVC) with intravenous (IV) fluids infusing. The client suddenly develops shortness of breath, and the nurse notes that the IV tubing and needleless connector device are disconnected. Which of the following actions should the nurse take first? Close the pinch clamp on the CVC. A nurse is assessing a client for fluid volume deficit following lumbar spinal surgery. The nurse should identify which of the following findings as an indication the client is at risk for fluid volume deficit? Surgical drain output 300 mL during an 8-hr shift A nurse is completing an admission assessment for a client who has bacterial meningitis. Which of the following personal protective equipment should the nurse use while caring for the client? Surgical mask A nurse in a long-term care facility is caring for a client who has dementia. Which of the following actions should the nurse take? Provide finger food at mealtime. A nurse is caring for a client who has multiple leg fractures and is 24 hr postoperative following placement of skeletal traction. Which of the following actions should the nurse take? Inspect the pin sites at least every 8 hr. A nurse is teaching a client about preventing the transmission of HIV. Which of the following information should the nurse include? Medication is available that will reduce the risk for HIV transmission. A nurse is assessing a client who recently had a myocardial infarction. Which of the following findings indicates that the client might be developing pulmonary edema? (Select all that apply.) Excessive somnolence Pink, frothy sputum Tachypnea A nurse is caring for a group of clients. In which of the following scenarios is the nurse acting as a client advocate? The nurse refers a client who has chronic obstructive pulmonary disease for palliative care services. A nurse is assessing a client who is undergoing radiation therapy for breast cancer. Which of the following findings is an indication to the nurse that the client is experiencing an adverse effect of the therapy? Skin changes A nurse is assessing a client who has a new diagnosis of pericarditis. Which of the following findings should the nurse identify as a manifestation of cardiac tamponade? Paradoxical pulse A nurse is caring for a client who is intubated and receiving mechanical ventilation for heroin toxicity. Which of the following assessments is the nurse's priority? ABGs A nurse is caring for a client who has deep-vein thrombosis and is receiving heparin via continuous IV infusion. The client's weight is 80 kg (176.4 lb). Using the client information provided, which of the following actions should the nurse take? Stop the heparin infusion for 1 hr. A nurse is preparing a teaching plan for a client who is starting to receive hemodialysis for chronic kidney disease. Which of the following instructions should the nurse include in the teaching? "Increase your intake of protein to 1 to 1.5 grams per kilogram per day." A nurse notes that a client's eyes are protruding slightly from their orbits. Which of the following laboratory findings should the nurse expect? Increased T 4 levels A nurse is caring for a client immediately following intubation with an endotracheal (ET) tube. Which of the following methods should the nurse identify as the most reliable for verifying placement of the ET tube? Check for end-tidal carbon dioxide levels. A nurse is teaching a client how to obtain a specimen at home for a fecal occult blood test. Which of the following actions should the nurse instruct the client to take for 3 days prior to collecting the specimen? Avoid eating red meat. A nurse is planning care for a client who had a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care? Turn the client by log rolling with a turning sheet. A nurse is caring for a client who is receiving a transfusion of packed RBCs. The nurse notes that the client's blood type is AB positive and the blood infusing is labeled type B negative. Which of the following actions should the nurse take? Monitor the client for any adverse reactions. A nurse is assessing a client who has a history of type 2 diabetes mellitus. The nurse should identify which of the following findings as an indication of a microvascular complication? Retinopathy [Show Less]
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ATI MEDICAL SURGICAL PRACTICE QUIZ FOR 2022-2023 ACTUAL EXAM
ATI MEDICAL SURGICAL PRACTICE QUIZ FOR 2022-2023 ACTUAL EXAM ATI MEDICAL SURGICAL PRACTICE QUIZ FOR 2022-2023 ACTUAL EXAM A nurse is reinforcing discha... [Show More] rge teaching about wound care with a family member of a client who is postoperative. Which of the following should the nurse include in the teaching? a.Administer an analgesic following wound care b.Irrigate the wound with povidone iodine. c.Cleanse the wound with a cotton tipped applicator. d.Report purulent drainage to the provider. ; d.Report purulent drainage to the provider. = A nurse is caring for a client who has bacterial meningitis. Upon monitoring the client, which of the following findings should the nurse expect? a.Flaccid neck b.Stooped posture with shuffling gait c.Red macular rash d.Masklike facial expression ; c.Red macular rash = A nurse is contributing to the plan of care for an older adult client who is at risk for osteoporosis. Which of the following interventions should the nurse include to prevent bone loss? a. Increase fluid intake. b. Encourage range-of-motion exercises. c. Massage bony prominences. d. Encourage weight-bearing exercises. ; d. Encourage weight-bearing exercises. = A nurse is collecting data from a client and notices several skin lesions. Which of the following findings should the nurse report as possible melanoma? a. Scaly patches b. Silvery white plaques c. Irregular borders d. Raised edges ; c. Irregular borders = A nurse is reinforcing discharge teaching to prevent dumping syndrome for a client following a partial gastrectomy for ulcers. Which of the following information should the nurse include in the teaching? a.Avoid liquids at mealtimes b.Exclude eating starchy vegetables c.Avoid eating high-protein meals d.Plan to increase intake of sweetened fruits ; a.Avoid liquids at mealtimes = A nurse is collecting data on a client who is scheduled for a cardiac catheterization. Which of the following laboratory levels should the nurse review prior to the procedure? a.Albumin b.phosphorus c.TSH d.BUN ; d.BUN = A nurse is reinforcing glycosylated hemoglobin (HbA1c) testing with a client who has diabetes mellitus. Which of the following statements indicates that the client understands the teaching? a. "The HbA1c test should be performed 2 hr after I eat a meal that is high in carbohydrates." b. "The HbA1c test can help detect the presence of ketones in my body." c. "I will have my HbA1c checked twice per year." d. "I will plan to fast before I have my HbA1c tested." ; c. "I will have my HbA1c checked twice per year." = A nurse is examining a client’s IV site and notes a red line up his arm. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client’s manifestations indicate which of the following complications of IV therapy? a.Thrombophlebitis b.Infiltration c.Hematoma d.Venous spasms ; a.Thrombophlebitis = A nurse is reinforcing teaching about management of constipation with a client who has hypothyroidism. Which of the following should the nurse include in the teaching? a. Increase intake of fiber-rich foods b. Take a laxative every morning c. Maintain a fluid intake of 1200 mL per day. d. Limit activity to preserve energy ; a. Increase intake of fiber-rich foods = A nurse is caring for a client who is at risk for developing pressure ulcers. Which of the following actions should the nurse take? a. Position pillows between the bony prominences. b. Check for incontinence every 3 hr. c. Massage reddened areas of the skin. d. Elevate the head of the bed to 45°. ; a. Position pillows between the bony prominences. = A 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? a. Place moist heat pads on the extremities. b. Perform manual massage of the affected extremities c. Dangle the extremities off the side of the bed. d. Apply support stockings before getting out of bed ; c. Dangle the extremities off the side of the bed. = A nurse is caring for a client who has meningococcal pneumonia. Which of the following personal protective equipment should the nurse use? a.gown b.mask c.sterile gloves d.protective eyewear ; b.mask = A nurse is reinforcing teaching about gastroesophageal reflux disease (GERD) with a client. Which of the understanding of the teaching? a. "I Should wait at least 2 hours after eating before going to bed." b. "I should eat three meals a day without eating snacks between meals." c. "I should season my food with garlic." d. "I should drink my liquids through a straw." ; a. "I Should wait at least 2 hours after eating before going to bed." = A nurse is caring for a client who is postoperative and has an epidural infusion. Which of the following findings should the nurse recognize as the priority? a.pruritis b.nausea c.urinary retention d.dyspnea ; d.dyspnea = A nurse is reinforcing teaching with a client who is taking insulin glargine. Which of the following information should the nurse include in the teaching? a. "This type of insulin should be given at the same time every day." b. "This insulin can be mixed with short-acting insulin in a single syringe." c. "This type of insulin can be used in a pump." d. "This insulin has an increased risk for hypoglycemia." ; a. "This type of insulin should be given at the same time every day." = A nurse is reinforcing teaching with an adolescent client regarding testicular self- examination. Which of the following statements by the client demonstrates an understanding of the teaching? a. “I will perform the exam before I shower.” b. “I will check my testicles every 6 months” c. "I understand that testicular cancer is painless." d. "I understand that pea-sized lumps are normal." ; c. "I understand that testicular cancer is painless." = A nurse is caring for a client who is scheduled for surgery and is experiencing anxiety. Which of the following interventions should the nurse identify as the priority? a. Determine the client's understanding of the procedure b. Encourage the client to express his feelings. c. Allow the client's family to stay with him. d. Provide music as a distraction. ; a. Determine the client's understanding of the procedure = A nurse is reinforcing teaching about home care with a client who had a knee arthroplasty. Which of the following factors should the nurse identify as an indication that a barrier to learning might be present? a. The client asks questions each time the nurse stops talking. b. The client stops the nurse and asks for pain medication c. While the nurse is speaking, the client refers to the written materials. d. A family member who is present asks the client to repeat important points. ; b. The client stops the nurse and asks for pain medication = A nurse is reinforcing discharge instructions with a client who is postoperative following a right hip arthroplasty. Which of the following statements should the nurse make? a. “You may cross your legs in 60 days b. "Avoid lying on your operative side c. "Avoid bending your hips more than 90 degrees." d. "You may sleep on a soft mattress”. ; c. "Avoid bending your hips more than 90 degrees." = A nurse is caring for a client who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days ago. Which of the following actions should the nurse take? a. Perform pin site care daily. b. Remove the overbed trapeze c. Remove the boot every 2 hr. d. Keep the weights on a stable, flat surface. ; a. Perform pin site care daily. = A nurse is assisting the charge nurse with developing an in-service about caring for clients who have internal sealed radiation implants. Which of the following information should the nurse include? a. Restrict the time pregnant women are allowed in the client's room to 15 min. b. Pick up a radiation implant with a double-gloved hand if it becomes dislodged. c. Limit time spent in the client's room to 2 hr during an 8 hr shift. d. Dispose of radiation implants in a lead container. ; d. Dispose of radiation implants in a lead container. = A nurse in a long-term care facility is collecting data from a client who reports fullness in the rectum and abdominal cramping. Which of the following findings should indicates to the nurse that the client might have a fecal impaction? a.halitosis b.hemorrhoids c.rebound tenderness d.small liquid stools ; d.small liquid stools = A nurse is providing discharge teaching for the family of a client who has Parkinson’s disease. Which of the following information should the nurse include in the teaching? a. Place the client on a low-calorie diet to prevent weight gain. b. Remind the client to avoid watching her feet when walking. c. Use small area rugs in the client's home for traction. d. Instruct the client to take tub baths instead of showers. ; b. Remind the client to avoid watching her feet when walking. = A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. Which of the following statements indicates that client is adhering to the nurse’s instructions? a. "I apply rubbing alcohol to my feet every day to prevent infection” b. "I will wear clean, knee-high wool socks every day to help improve my circulation”. c. "I use hot water bottles to keep my feet warm at night”. d. "I don't cross my legs anymore." ; d. "I don't cross my legs anymore." = A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an IV contrast agent. Which of the following laboratory findings should the nurse report to the provider prior to the procedure? a.Sodium 136 b.Potassium 4.8 c.Creatinine 1.9 d.calcium 10 ; c.Creatinine 1.9 = A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infections in a surgical wound. Which of the following information should the nurse plan to share with visitors? a.Visitors should call prior to visiting the client b.Visitors must don a gown and gloves prior to entering the client's room. c.Visitors need to wear a mask when in close proximity to the client. d.Visitors may not bring fresh flowers into the client's room. ; b.Visitors must don a gown and gloves prior to entering the client's room. = A nurse is reinforcing teaching about dietary changes with a client who has cardiovascular disease. Which of the following images indicates the type of cooking fat the nurse should recommend the client use when preparing meals? a.butter b.coconut oil c.olive oil d.shortening ; c.olive oil = A nurse is reinforcing teaching with a client who has heart failure and a new prescription for hydrochlorothiazide. Which of the following findings should the nurse instruct the client to report to the provider? a.onset of nausea b.increased urinary output c.weight loss of 0.9 kg (2lb) per week d.missed dose of the medication ; a.onset of nausea = A nurse is preparing to suction a client who has a tracheostomy. Which of the following actions should the nurse take first? a. Insert the suction catheter into the tracheostomy. b. Rinse the catheter with sterile 0.9% sodium chloride. c. Ventilate with 100% oxygen. d. Occlude the vent on the catheter for 10 seconds. ; c. Ventilate with 100% oxygen. = A nurse is reinforcing teaching with a client who is on a low-sodium diet and asks about how to improve the taste of bland food. Which of the following should the nurse recommend? a.ketchup b.mayonnaise c.soy sauce d.lemon juice ; d.lemon juice = A nurse is reviewing the medical record of a client who has a prescription for morphine. Which of the following findings should the nurse reports to the provider? a.urinary retention b.administration of celecoxib 24 hr ago c.history of immunosuppression d.administration of levothyroxine 12 hr ago ; a.urinary retention = A nurse is caring for a client who is 13 days postoperative following a total right hip arthroplasty. Which of the following actions should the nurse take? a. Use a traction boot to keep the client's right leg internally rotated. b. Have the client sit in a reclining chair when out of bed c. Maintain abduction of the client's right leg while in bed. d. Encourage the client to perform passive range-of-motion exercises. ; c. Maintain abduction of the client's right leg while in bed. = A nurse is monitoring a client who is taking acarbose. Which of the following findings should the nurse identify as an adverse effect of the medication? a.polyuria b.abdominal cramps c.renal insufficiency d.insomnia ; b.abdominal cramps = A nurse is reviewing the laboratory results of a client who has chronic kidney failure and is receiving epoetin alfa. The nurse should identify that which of the following laboratory values indicates the treatment is effective? a.BUN 40 b.HGB 11 c.Urine specific gravity 1.035 d.Blood glucose 105 ; b.HGB 11 = A nurse is reinforcing discharge teaching with a client who has hearing loss. Which of the following actions should the nurse take when communicating with the client? a. Rephrase client instructions when not understood. b. Cup hands around the mouth and direct speech toward the client c. Accentuate vowel sounds by using a higher pitch when speaking. d. Sit to the side of the client and speak instructions into her best ear. ; a. Rephrase client instructions when not understood. = A nurse is caring for a client who is 1 day postoperative following a hip arthroplasty. The client is exhibiting hypotension, tachycardia, and tachypnea. The nurse should recognize that these findings indicate which of the following complications? a.wound infection b.pulmonary embolism c.thrombophlebitis d.paralytic ileus ; b.pulmonary embolism = A nurse is monitoring a client who recently had a cast placed on the right lower extremity for a bone fracture. Which of the following findings should the nurse recognize as abnormal? a. Report of a dull, throbbing pain b. Extremities that are cool bilaterally c. Capillary refill of 3 seconds in the nail beds of the toes d. Lack of sensation between the first and second toes ; d. Lack of sensation between the first and second toes = A nurse is caring for a client who has a history of breast cancer. The client asks the nurse about birth control. Which of the following methods of birth control is contraindicated for this client? a.IUD b.Latex condom c.Combination oral contraceptives d.Contraceptive sponge ; c.Combination oral contraceptives = A nurse is collecting data from a client who has heart failure and is taking digoxin. Which of the following outcome from the medication should the nurse expect? a.increased weight b.increased heart rate c.decreased urinary output d.decreased shortness of breath ; d.decreased shortness of breath = A nurse is reinforcing teaching with a client who has systemic lupus erythematosus (SLE) and is to begin taking methylprednisolone orally. Which of the following statements should the nurse include in the teaching? a. "Take the medication on an empty stomach." b. "Limit contact with large groups of people." c. "Avoid taking over-the-counter calcium supplements." d. "Follow a low-protein diet." ; b. "Limit contact with large groups of people." = A nurse is caring for a client who is 24 hr. postoperative following abdominal surgery and has an NG tube. Which of the following actions should the nurse plan to take to decrease the risk of postoperative complications? a. Offer sips of water to the client following oral care. b. Massage the client's lower extremities with lotion every 2 hr. c. Encourage the client to use an incentive spirometer every hour while awake. d. Place one or two pillows beneath the client's knees while he is in bed. ; c. Encourage the client to use an incentive spirometer every hour while awake. = A nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for baclofen. Which of the following instructions should the nurse include in the teaching? a. Consume a low-purine diet. b. Avoid stopping this medication suddenly. c. Use chamomile tea to alleviate insomnia. d. Take this medication on an empty stomach. ; b. Avoid stopping this medication suddenly. = A nurse reviewing the laboratory results of a client who has type 2 diabetes mellitus. The nurse should identify that which of the following laboratory values indicates the client is at risk for delayed wound healing? a. HbA1c 6% b. Prealbumin 12 mg/dL c. WBC 8,000/mm3 d. Creatinine 0.8 mg/dL ; b. Prealbumin 12 mg/dL = A nurse is assisting with the discharge planning for a client who is postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the discharge plan? a. Expect decreased sensation for the first postoperative week. b. Avoid lying on the operative side. c. Obtain a raised toilet seat. d. Cross legs at the ankles. ; c. Obtain a raised toilet seat. = A nurse is preparing to move a client’s NG tube. Which of the following interventions should the nurse take to decrease the risk of aspiration? a. Instill 10 mL of air through the NG tube. b. Place the client in the supine position. c. Irrigate the NG tube. d. Pinch the NG tube. ; d. Pinch the NG tube. = A nurse is collecting data from a client who has chronic kidney disease with hyperkalemia. Which of the following findings should the nurse expect related to hyperkalemia? a.polyuria b.constipation c.anorexia d.braydcardia ; d.braydcardia = A nurse is reinforcing teaching with a client who has asthma. Which of the following client statements indicate an understanding of the use of budesonide and albuterol inhalers? (Select all that apply.) a. "I should expect to feel sleepy after using my albuterol inhaler" b. "I never forget to rinse my mouth after using my budesonide inhaler. c. "Between office visits, I keep a record of how many times I use my albuterol inhaler”. d. "I use my albuterol inhaler before I go swimming" e. "I should use my budesonide inhaler before using my albuterol inhaler" ; b. "I never forget to rinse my mouth after using my budesonide inhaler. c. "Between office visits, I keep a record of how many times I use my albuterol inhaler”. d. "I use my albuterol inhaler before I go swimming" = A nurse is caring for a client and administers penicillin IM. the client begins exhibiting hives and has severe difficulty breathing. After establishing a patent airway, which of the following actions should the nurse take next? a. Administer epinephrine. b. Monitor the client's vital signs. c. Monitor the client's oxygen saturation level. d. Administer an antihistamine. ; a. Administer epinephrine. = A nurse is reinforcing teaching with a client who has mitral valve disease. Which of the following statements by the client indicates an understanding of the disease process? a. "I should call my doctor if I get a headache." b. "I may develop gastric reflux." c. "I may develop excessive bruising." d. "I should call my doctor if my ankles swell." ; d. "I should call my doctor if my ankles swell." = A nurse is monitoring an older adult client who has a history of an enlarged prostate and is experiencing suprapubic discomfort. Which of the following actions should the nurse take first? a. Administer doxazosin. b. Palpate the abdomen. c. Insert an indwelling urinary catheter. d). Notify the primary care provider. ; b. Palpate the abdomen. = A nurse is contributing to the plan of care for a client who has chronic obstructive pulmonary disease (COPD) and is dyspneic. Which of the following interventions should the nurse include in the plan? a. Encourage abdominal breathing. b. Direct the client to inhale with pursed lips. c. Set the oxygen therapy at 5 L/min. d. Instruct the client to lean back when coughing. ; a. Encourage abdominal breathing. = A nurse is assisting in the care of a client who has manifestations of sepsis. Which of the following provider prescriptions should the nurse implement first? a. Collect a sputum culture b. Administer ceftriaxone by intermittent IV bolus c. Initiate oxygen at 4 L/min via nasal cannula. d. Obtain blood cultures. ; c. Initiate oxygen at 4 L/min via nasal cannula. = A nurse is caring for a client who has terminal pancreatic cancer. The client states, “I don’t think i can go on any longer.” Which of the following responses should the nurse make? a. "Can I get you something for the pain?" b. "You should talk about this with your family." c. "Tomorrow will be a better day." d. "Tell me more about the way you are feeling." ; d. "Tell me more about the way you are feeling." = A nurse is collecting data from a 55-year old female client who reports vaginal dryness and 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? a. Five-year history of menopause manifestations b. History of treatment for blood clots c. Topiramate use for migraine headaches d. Increased serum cholesterol levels ; b. History of treatment for blood clots = A nurse in an oncology clinic is reinforcing teaching is reinforcing teaching about Mohs surgery with a client who has skin cancer. Which for the following information should the nurse include in the teaching? a. Mohs surgery is a horizontal shaving of thin layers of the tumor. b. Mohs surgery uses liquid nitrogen to destroy the cancerous tissue. c. Mohs surgery is the preferred treatment for melanoma skin cancer. d. Mohs surgery is a palliative treatment for metastatic skin cancer. ; a. Mohs surgery is a horizontal shaving of thin layers of the tumor. = A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse identify as the priority? a.muscle weakness b.dysrhythmia c.abdominal pain d.lethargy ; b.dysrhythmia = A nurse is caring for an older adult client who has reddened area over the sacrum. Which of the following actions should the nurse take? a. Minimize the time the head of the bed is elevated. b. Apply a sterile gauze dressing to the site. c. Massage the site with moisturizing lotion. d. Place a donut-shaped cushion under the client's sacral area. ; a. Minimize the time the head of the bed is elevated. = A nurse is caring for a client who is in Buck’s traction. Which of the following interventions should the nurse perform to reduce skin breakdown? a. Keep the skin dry and free of perspiration. b. Use hot water and antibacterial soap to bathe the client. c. Massage the skin over bony prominences to promote circulation. d. Limit the use of moisturizers on the skin over bony prominences. ; a. Keep the skin dry and free of perspiration. = 62. A nurse is contributing to the plan of care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infections and is on contract isolation precautions. Which of the following actions should the nurse take? a. Keep the door of the client's room closed at all times b. Remove gloves after leaving the client's room. c. Wear a mask when working within 1 m (3 feet) of the client. d. Have a designated stethoscope in the client's room. ; d. Have a designated stethoscope in the client's room. = A nurse is caring for a client who has a prescription for phenazopyridine. Which of the following findings should the nurse identify as a therapeutic effect of the medication? a. Reduces bacteria in the urinary tract b. Suppresses urge to void c. Prevents nerve stimulation to the bladder muscle d. Decreases pain during urination ; d. Decreases pain during urination = A nurse is reinforcing discharge teaching with a client who has cirrhosis. Which of the following instructions should the nurse include? a. "You can take acetaminophen for pain." b. "Consume a diet high in animal protein." c. "Sleep lying flat on your back." d. "Consume foods low in sodium." ; d. "Consume foods low in sodium." = A nurse is planning to implement droplet precautions for a client who has manifestations of pertussis. Which of the following interventions should the nurse include when contributing to the plan of care? a. Apply a mask on the client if transport is needed. b. Wear a mask when working within 4 feet of the client. c. Don a gown when visiting with the client d. Wear an N95 mask when entering the client's room. ; a. Apply a mask on the client if transport is needed. = A nurse is assisting a client who reports difficulty falling asleep. Which of the following activities should the nurse recommend to promote sleep? a. Get out of bed if unable to fall asleep within 60 min. b. Take a brisk walk before sleeping. c. Listen to soft music before sleeping. d. Drink adequate amounts of fluids before sleeping. ; c. Listen to soft music before sleeping. = A nurse is caring for a client who has an acute ischemic stroke 1 day ago. Which of the following actions should the nurse take to reduce the risk for aspiration? a. Allow for 30 min of rest before meals. b. Provide a straw for drinking liquids. c. Serve foods at room temperature. d. Place 2 tsp of food in the client's mouth at a time. ; a. Allow for 30 min of rest before meals. = A nurse enters the room of a client whose transfusion of packed RBCs was initiated 15 min ago by the RN. The client reports dyspnea and urticaria. Which of the following actions should the nurse perform first? a. Count the client's respiratory rate. b. Ask the client if chest pain is present. c. Stop the infusion. d. Administer an antihistamine. ; c. Stop the infusion. = A nurse is reinforcing teaching with the family of a client who has a cervical injury and has a halo vest in place. Which of the following safety precautions should the nurse include in the teaching? a. Clean the pin sites every 72 hr. b. Use the halo ring to reposition the client when in bed. c. Change the sheepskin liner weekly. d. Tighten the traction bar as needed. ; c. Change the sheepskin liner weekly. = A nurse is preparing to auscultate the bowel sounds of a client who has a mechanical bowel obstruction in the descending colon. When listening in the left upper quadrant, the nurse should identify this sound as which of the following? (Click on the audio button to listen to the clip.) a) Hyperactive bowel sounds b) Friction c) Normal bowel sounds d) Abdominal bruit ; a) Hyperactive bowel sounds = A nurse is reinforcing teaching with a client a client who has gonorrhea. Which for the following information should the nurse include? a) "Your partner will not require treatment for this infection." b) "You can resume sexual activity as soon as you begin treatment." c) "You are at risk for infertility with this infection, regardless of treatment." d) "You will not be at further risk for this infection following treatment.” ; c) "You are at risk for infertility with this infection, regardless of treatment." = A nurse is assisting in the plan of care regarding bowel retraining for a client who has cervical spinal cord injury. Which of the following interventions should the nurse plan to implement first? a) Determine the client's daily elimination habits. b) Administer a suppository to the client 30 min prior to defecation time. c) Offer the client 4 oz of warm prune juice to promote elimination. d) Provide dietary bulk to the client to ease the passage of stool. ; a) Determine the client's daily elimination habits. = A nurse is contributing to the plan of care for a client who was admitted to the neurological unit following a stroke 3 hr. ago. Which of the following interventions should the nurse identify as the priority? a) Encourage the client to participate in self-care. b) Assist the client with active range-of-motion exercises. c) Keep the client in a side-lying position d) Maintain the client's body alignment. ; c) Keep the client in a side-lying position = 74. A nurse is preparing to administer furosemide to a client who has heart failure. Which of the following findings should the nurse report before administering the medication? a) Elevated sodium b) Elevated blood pressure c) Decreased potassium d) Decreased urine output ; c) Decreased potassium A nurse observes a client who is lying in bed experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? a) Lower the side rails of the client's bed. b) Apply wrist restraints to the client. c) Position the client in the semi-Fowler's position. d) Loosen clothing around the client's neck. ; d) Loosen clothing around the client's neck. = A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis. Which of the following information should the nurse include in the teaching? a) Apply cold packs to the inflamed joints. b) Participate in high-impact exercise. c) Carry a hand purse rather than a shoulder bag. d) Sleep on a soft foam mattress. ; a) Apply cold packs to the inflamed joints. = A nurse is participating in a health fair for older adult clients. Which for the following immunizations should the nurse recommend for this age group? a) Meningococcal b) Herpes zoster c) Human papillomavirus (HPV) d) Measles, mumps, and rubella (MMR) ; b) Herpes zoster = A nurse is caring for a client who has difficulty swallowing. Which of the following actions should the nurse implement to prevent aspiration? a) Provide small, frequent meals. b) Tell the client to extend his neck when swallowing. c) Provide mouth care before meals. d) Give the client liquids with increased viscosity. ; d) Give the client liquids with increased viscosity. = A nurse is contributing to the plan of care for a client who has a new prescription for nystatin suspension for oral candidiasis. Which of the following interventions should the nurse include in the plan? a) Use a commercial mouthwash before taking the medication. b) Instruct the client to swish the medication in her mouth. c) Discontinue the medication as soon as the lesions are healed. d) Combine the medication with applesauce. ; b) Instruct the client to swish the medication in her mouth. = A nurse is collecting data from a client who has hypothyroidism. Which of the following manifestations should the nurse anticipate? a) Blurred vision b) Insomnia c) Bradycardia d) Weight loss ; c) Bradycardia = A nurse is discussing health screening guidelines with an older adult client. Which of the following statements should the nurse include? a) "You should have a screening for glaucoma every 5 years." b) "You should have a physical examination every other year." c) "You should have your hearing checked every 2 years” d) "You should have a pneumococcal immunization every 10 years” ; d) "You should have a pneumococcal immunization every 10 years” = A nurse is assisting with the care of a client who is receiving 0.9% sodium chloride by continuous IV infusion. The client reports pain and swelling at the IV site. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in order of performance. Use all the steps.) Steps: Notify the charge nurse Stop the infusion. Elevate the affected arm. Withdraw the IV catheter. Check the IV site. ; Check the IV site Stop the infusion. Withdraw the IV catheter. Elevate the affected arm. Notify the charge nurse = A nurse is contributing to the plan of care for a client who is postoperative following a total knee arthroplasty. The client is using a continuous passive motion (CPM) machine. Which of the following interventions should the nurse recommend for the plan of care? a) Store the CPM machine on the floor when it is not in use b) Keep a sheepskin pad between the client's extremity and the CPM. c) Check the cycle and range-of-motion settings at least every 12 hr d) Align the frame joint of the CPM with the middle of the client's calf. ; b) Keep a sheepskin pad between the client's extremity and the CPM. = A nurse is caring for a client who has acute pancreatitis. While providing care, the nurse observes ecchymosis around the umbilicus. The nurse should identify that this is a manifestation of which of the following? a) Cirrhosis of the liver b) Hypermotility of the bowel c) Intra-abdominal bleeding d) Acute cholecystitis ; c) Intra-abdominal bleeding = A nurse is caring for a client who is receiving chemotherapy. The client mentions that she has a loss of appetite because she has sores in her mouth and that food no longer tastes good. Which of the following suggestions to the client should the nurse make? a) Drink water before and after each bite b) Consume foods that are served hot rather than cold c) Rinse with a glycerin-based mouthwash before meals. d) Eat several, small-portioned meals daily ; d) Eat several, small-portioned meals daily = A nurse is contributing to the plan of care for a client who is having difficulty eating following a stroke. Which of the following interventions should the nurse plan to implement first? a) Collaborate with a dietitian b) Provide nutritional supplements. c) Recommend a referral for a speech language pathologist d) Inform assistive personnel about proper positioning. ; c) Recommend a referral for a speech language pathologist = Following a blood draw procedure for a fasting blood sugar (FBS) test, a client tells the nurse, “I’m glad they took my blood because I’m really hungry. All I’ve had since midnight is water and some juice.” Which of the following actions should the nurse take? a) Offer the client breakfast then repeat the FBS request b) Reschedule the FBS test for early the next morning. c) Request that the phlebotomist obtain another specimen d) Ask the laboratory technician to repeat the test on the same specimen ; b) Reschedule the FBS test for early the next morning. = A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking dantrolene to manage muscle spasms. Which of the following interventions should he nurse include? a) Apply hot packs to the client's muscles. b) Schedule physical therapy in the afternoon c) Encourage the client to complete ADLs. d) Administer valerian to promote sleep. ; c) Encourage the client to complete ADLs. = A nurse is preparing to administer scheduled medications to a client. Which of the following prescriptions should the nurse verify with the provider? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.) Exhibit 1-History and Physical History of type 2 diabetes mellitus and Allergies: 1) Penicillin reaction severe 2) Aspirin 3) Heparin Exhibit 2-Nurses’ Note 0730 Vital signs Temperature 38° C (100.4° F) Heart rate 72/min and regular Respiratory rate 16/min Blood pressure 128/78 mm Hg Pain rating 6/10 Exhibit 3-Diagnostic results Capillary glucose 102 mg/dL a.ceftriaxone b.diltiazem c.pioglitazone d.hydrocodone/acetaminophen ; a.ceftriaxone = A nurse is caring for a client who is postoperative and receiving an IV infusion of cefazolin. Ten minutes after beginning the infusion, the client reports intense itching. Which of the following actions should the nurse take first? a.stop the medication infusion b.notify the charge nurse c.administer a PRN dose of diphenhydramine d.follow facility policy for appropriate reporting of the adverse reaction ; a.stop the medication infusion = [Show Less]
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