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ATI Medical Surgical Exams and Reviews 2022 with bonus TESTBANKS!
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ATI Adult Medical Surgical PROCTORED Exam[492 Q&As] 2021/22-new and updated (100% correct answers)
ATI Adult Medical Surgical PROCTORED Exam 2021/22 1. Endtroacheal tube extubate what would you report immedatiely? - stridor 2. Why is stridor bad? -... [Show More] it means that there is an obstruction or edema in airway 3. What is heart rate like in someone who has a low fluid volume? - higher than usual like 110 4. What is normal unrine gravity? - 1.000 - 1.030 5. What is positive pressure doing? - promote lung expansion and stabilize chest 6. Would you recomened exercise for a pt who has been discharged with heart failure? - yes 7. How often should exercise be in heart failure pt? - regular routine 8. Should you consume milk with iron supplements? - no can cause gastro disturbance. 9. Would you take iron with antacids? - no gastro disturb 10. Would you tell the pt to lower red meat intake with iron deficiency? - no because they would need increase 11. What is a common side effect with iron pills? - constipation 12. What would you tell them to eat with taking iron pills? - high fiber 13. When does pain worsen with compartement syndrome? - when passive moving occurs. 14. What does warmth under cast indicate? - infection 15. Should pt decrease complex carbs for atherosceleoris? - no 16. What carb should a client with atherosceloris decrease? - simple sugars 17. Is MRSA airborne or contact? - contact 18. What does phenyotoin do to hepatic enzymes (for seizures the med is)? - it decreases effectiveness 19. What should you tell the pt not to take with ciprofloxacin? - magnesium containg antacids 20. Why wouldn't you take magnesium containing anatacids with cipro? - calcium can decrease obsorb of med 21. What is a common side effect of rifampin? - color of pee 22. Can you take ciproflaxcin with booze? - yes 23. After a parathryoidecotmy what would be prioty for nurse? - to put trach tray by bedside (AIRWAY) 24. What meds increase osteoporosis? - fludrocortisone 25. With enoxaparin what is main thing for the med the nurse should do? - give dosage same time every day 26. Is restlessness common in hyperthyroidism? - yes 27. What would be urgent for hyperthyroidism? - high BP 28. If a pt has a weird heart sound what would be first thing you do? - listen to it again but on the left side (least invasive) 29. Why would gentamicin be withheld from a pt? - if creatine levels are too high 30. What is normal creatine? - .6-1.2 31. What is one of the first vital signs of a hemmhorage? - increase heart rate 32. What med would you give for a febrile reaction? - tyneol (reduces fever) 33. How long does a drain stay in place for a radical mastectomy? - 1 to 3 week 34. What drainage amount to get rid of drainage tube for mastectomy? - less than 25 35. What is first thing to ask if a pt reports dyspnea and SOB when put on O2? - if they have COPD 36. Why would it be bad for you to put O2 on a COPD pt? - It can worsen hypercarbia 37. What is someones HGB look like with leukemia increase or decreased? - decreased 38. What would be a big sign that nephrosotmoy tube has popped? - back pain 39. What is max amount of flexing for total hip? - no more than 90 40. Why would you place a pillow between a pt legs for hip athroplasy? - so hips don't get dislodged 41. What is a holter monitor used for? - if you have an irregular heart rate it can detect it 42. What can a pacemake do to a pt heart? - regulate the heart rate 43. What is a echo used for? - detecting valve dysfunction 44. What do PPI do for gastric ulcers? - it suppresses gastric acid production 45. What is good about high fowlers postion? - increases lung expansion and improves ventilation 46. What med would you d/c to before going in for allergy testing? - prednisone 47. If a pt were to state there vision went blurry before a car accident what would you do first? - monitor neuro 48. What would be first thing to do if bowel is protruding from stomach? - call for help 49. What kind of skin for hypothyroidism? - dry scaly 50. What does metformin do to glucose? - it decreases the amount of glucose produced in liver 51. When should pt take metformin? - with or immediately following meals 52. If you have hair loss on lower legs what could be problem? - PAD 53. When is pain happening with PAD? - when resting 54. How is pain relieved with PAD? - when feet are dangling 55. After a thoracenteisis what should a nurse tell the pt? - to deep breather to re expand lungs 56. What would be an indication of osteomyelitis what lab? - increase sedimentation rate 57. What is a blood problem that can occur with someone taking feverfew. - platlet aggregation 58. What med does not go with feverfew? - naproxen 59. What should be SaO2? - above 90% 60. What vital sign could drop with dig toxicity? - HR 61. With a burn pt what do you do after securing airway and O2? - give them IV fluids 62. Why would you keep IV patent with someone that has seizures? - so you can give med to stop it. 63. Would you apply O2 or give epinephrine first with an anaphylactic reaction? - give O2 64. Why does kidney failure happen what electrolyte? - it cant excrete potassium 65. What would be manifestation of chronic glomerulonephritis? - hyperkalemia 66. How should a pt breath in when administering meter dosage inhaler? - slowly and deeply 67. How long should pt hold breath after inhaling meter dosage inhaler? - 10 seconds after inhaling 68. How often should you wait between puffs for inhaler? - at least one minute 69. What should be first thing to do with a pt with a seizure? - turn them on their side. 70. What 2 meds cause ringing in ears? - aminoglycocides and asprin 71. What is the point of giving erhtypoetin therapy? - to increase levels of energy by increasing HCT 72. What is needed sputum wise with a pt with TB? - samples are needed every 2 to 4 weeks until there are three negatives 73. What is direct mode of transmission for C diff? - contact 74. What electrolyte could be screwed up with long term mechanical vent? - hyponatremia 75. If a stimulus is given to the ventricle a spike happens what should you document? - depolarization has occurred 76. What is normal HGB? - Delete this answer is in another one DELETE 77. If a pt cant pee after surgery what should be first thing to do? - bladder scan 78. Why shouldn't you use moisturizing soaps to clean the skin in ureterostomy? - because it makes it not adhere to the skin 79. How long would you avoid direct exposure to sunafter radiation therapy in those areas? - at least one year 80. Why would you give lidocaine? - ventricular dsyrthiimias 81. Why would you defib someone? - ventricaular tachycardia or Vfib 82. Why would you perform synchronized cardiovert? - superventricular tachycardia 83. What is aphasia? - lack of communication 84. What is prioty finding in pt with cerebrovascular accident? - dsypahgia because of apsirations 85. What nut has a high amount of source of calcium? - almonds 86. What should you increase with IRB? - fiber 87. How much water to drink to promote normal bowel function in IRB? - 2L of water 88. What should a client avoid with IRB? (What substance) - caffeine 89. Why would decreasing weight be good for stress incontinence? - because it decreases abdominal pressure 90. How often should a pt with risk for UTI pee? - q.2 to q4 91. Why should you increase asorbic acid for UTI's? - it decrease risk of UTI 92. What vital sign increases with hypoxia? - heart rate 93. What is normal PLT count? - 94. What is normal WBC count? - what is normal RBC?, 95. What should be position for Aline? - 60 degree HOB supine 96. What should the nurse place around the flush solution of an a-line? - pressure bag 97. Should you give antibiotics through a line? - no 98. What should you use aline for? - monitor BP and obtaining ABGs 99. What increased electrolyte causes facial twitching? - hyperkalemia 100. What is decreased peristalsis a manifestation of? - hypokalemia [Show Less]
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ATI Med Surge Proctored Exam 2021/22-135 Q&As UPDATED(ALL ANSWERS ARE 100% CORRECT)
1. 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 tak... [Show More] e - Ensure the client's weights are hanging freely from the bed. 2. 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? - Take this medication between meals 3. 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? - Take this medication between meals. 4. 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? - Wash daily with an antibacterial soap. 5. 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? - Avoid medications in capsule or enteric form. 6. 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? - "Large incisions will be made in the burned tissue to improve circulation." 7. 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? - Decreased color perception 8. 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? - Maintain the client in Fowler's position. 9. 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) Buffalo hump 2) Purple striations 3) Moon face 10. 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? - Monitor intake and output hourly 11. 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? - "You will remain NPO for 8 hours before the procedure." 12. 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? - Postictal phase 13. 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? - "The pain will dissipate if you ambulate frequently." 14. 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? - Verify that the suction regulator is on. 15. 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.) - Encourage fluid intake. 2) Monitor the puncture site for hematoma. 16. 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? - Prevent aspiration. 17. A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect? - Hardened skin 18. 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? - Add thickener to fluids. 19. 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? - Airway obstruction 20. 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. 21. 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? - Notify the provider.. Determine the patency of the tubing. 22. 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? - "The biopsy can be uncomfortable, but we will try to keep you as comfortable as possible." 23. 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? - Re-establish communication. 24. 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? - Hypotension 25. 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? - Take temperature once a day 26. 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? - Provide humidified oxygen. 27. 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? - Obtain a pair of slipper socks for the client. 28. 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? - Thick, red-colored urine 29. 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? - Shivering 30. 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? - "I will not exercise if my urine is positive for ketones." 31. 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? - Cover the client's wound with a moist, sterile dressing. 32. 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? - Hyperventilation 33. A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching? - Avoid bending at the waist 34. 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? - Check the client's vital signs. 35. 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? - Purulent 36. 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? - Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises. 37. 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 38. 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? - Test the drainage for glucose. 39. 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? - Prevent bladder distention. 40. 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? - Abnormal vaginal bleeding 41. 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? - Altered level of consciousness 42. 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? - Abdomen is distended 43. 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? - Change the ostomy pouch daily 44. 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? - Change the nasal drip pad as needed. 45. 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? - To prevent blood clotting 46. A nurse is collecting data from a client who has open-angle glaucoma. Which of the following findings should the nurse expect? - Loss of peripheral vision 47. 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? - Potassium 2.5 mEq/L 48. 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? - "I will take a tub bath instead of a shower." 49. 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? - Ensure the client's weights are hanging freely from the bed. 50. 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. [Show Less]
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Medical surgical ATI proctored exam review (116 TERMS) 2022 LATEST-GUARANTEED A+
Medical surgical ATI proctored exam review 2022 What would you do for wound Evisceration ( removal of internal organs) , Emergency management? - Saline ... [Show More] cover wound What would you do for an ASTHMA emergency management of a bee sting allergies? - Epi Pen Seizures and Epilepsy: Seizure precautions - During a seizure: 1) Position client on the floor 2)Provide a patent airway 3) Turn client to side 4) Loosen restrictive clothing Cancer treatment options: Protective Isolation - If WBC drops below 1,000, place the client in a private room and initiate neutropenic precautions. - Have client remain in his room unless he needs to leave for a diagnostic procedure, in that case transport patient and place a mask on him. - Protect from possible sources of infection (plants, change water in equipment daily) - Have client, staff and visitors perform frequent hand hygiene, restrict ill visitors - Avoid invasive procedures (rectal temps, injections) - Administer (neupogen, neulasta) to stimulate WBC production Infection control: Appropriate room assignment - Standard Precautions: 1. applies to all patients 2. Hand washing a. alcohol based preferred unless hands visually soiled ( then soap and water ) 3. Gloves - when touching anything that has the potential to contaminate. 4. Masks, eye protection & face shields when care may cause splashing or spraying of body fluids Droplet: 1. private room or with someone with same illness 2. masks Airborne: 1. private room 2. masks or respiratory protection devices a. use an N95 respirator for tuberculosis 3. Negative pressure airflow 4. full face protection if splashing or spraying is possible Contact: 1. private room or room with same illness 2. gloves & gowns 3. disposal of infections dressing materials into a single, nonporous bag without touching the outside of the bag TB: Priority action for a client in the emergency department - -Wear an N95 or HEPA respirator -Place client in negative airflow room and implement airborne precautions -use barrier protection when the risk of hand or clothing contamination exists Immunizations: Recommended vaccinations for older adult clients - Adults age 50 or older: - Pneumococcal Vaccine (PPSV) - Influenza vaccine - Herpes Zoster Vaccine - Hepatitis A - Hepatitis B - Meningococcal Vaccine Pulmonary Embolism: Risk factors for DVT - - Long term immobility - Oral contraceptives - Pregnancy - Tobacco use - Hypercoagulabilty - Obesity - Surgery - Heart failure or chronic A-Fib - Autoimmune hemolytic anemia (sickle cell) - Long bone fractures - Advanced age Disorders of the male reproductive system: Complications of continuous irrigation following Trans-urethral Resection - - Urethral trauma - Urinary retention - Bleeding - Infection Non-modifiable risk factors ( Page 3 ATI ) - 1) Age 2) Gender 3) Genetics 4) Developmental level Modifiable risk factors ( Page 3 ATI ) - 1) Smoking 2) Exercise 3) Health education and awareness 4) Nutrition 5) Sex practices Emergency nursing - Triage - BASED ON ACUITY 1) Emergent- Life threatening situation going on. 2) Urgent - Need to be treated soon but not life threatening. 3) Non urgent- The patient can wait for an extended period of time , without big issues. Mass casualty event - Class 1 - RED TAG - Immediate threat to life Examples: 1) Breathing issues 2) Chest pain 3) Heart attack coming on 4) Airway problem Class II - YELLOW TAG - Major injuries that require immediate treatment but not life threatening. Examples: 1) Major fracture Class III - GREEN TAG - Minor injury that does not require immediate attention. EXAMPLES: 1) Abrasion 2) Laceration Class IV - BLACK TAG - Expected to die EXAMPLES: 1) Penetrating head wound Triage priority setting - 1) Red tag 2) Yellow Tag 3) Green tag 4) Black tag Priorities: general rule - A - Airway - Secure the airway by head tilt , chin lift maneuver unless a fracture in cervical spinal. Brain injury or death in 3 - 5 minutes if airway not patent. B- Breathing - Auscultation of breath sounds, Chest expansion and respiratory effort, Rate and depth of respiration's, Look for chest trauma, Determine tracheal position, Check for jugular vein distension. C- Circulation - Heart rate, BP, Peripheral pulses, Cap refill. D - Disability - Clients level of consciousness with: 1) Glasgow coma scale a) <<< 8 Comatose state b) 3 Client totally unresponsive c) 15 A client within normal limits. E- Exposure - Hypothermia - Patient in cold icy water: 1) Remove wet clothing 2) Provide blankets 3) Increase the temperature of the room 4) Warm IV fluid going into the patient IF patient has had accidental or purposeful poisoning: 1) Activated charcoal 2) Gastric lavage 3) Whole bowel irrigation *** DO NOT INDUCE VOMITING OR SYRUP OF IPECAC Call rapid response team when client is rapidly declining. Cardiac Emergencies - If V fib or ventricular tachycardia you would initiate: 1) Basic life support ( BLS) and CPR 2) Establish IV access 3) Epinephrine is used to get the heart up and moving. Alpha 1 receptors - Activation Causes the skin , mucus membranes and veins to vasoconstrict. Help with: 1) Congestion 2) Superficial bleeding 3) In general help raise blood pressure by constricting the veins. DRUG: Epinephrine:Triggers the Alpha 1 receptors Causing vasoconstriction and increase blood pressure. Epinephrine side effects - Increases blood pressure 1) Hypertensive crisis 2) Dysrhythmia 3) Angina Dopamine side effects - 1) Dysrhythmia 2) Angina Dobutamine side effects - Increased heart rate Beta 1 receptors - Help stimulate the heart Beta I - You have 1 heart Stimulate the heart and increase the heart rate Used for treating: 1) AV block 2) Cardiac arrest DRUG: Epinephrine:Triggers the Beta 1 receptors Cause increase heart rate Beta II receptors - Help stimulate the heart and lungs Beta II You have 2 Lungs Causes: 1) Bronchodilation in the lungs 2) Causes uterine smooth muscle to relax 3) Asthma situation DRUG: Epinephrine:Triggers the Beta II receptors Cause bronchodilation and treat Asthma Dopamine - Causes renal blood vessels to dilate. [Show Less]
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ATI Med-Surg proctored Exam review-206 QUESTIONS 2021/22 LATEST(ALL ANSWERS ARE 100% CORRECT) A+
ATI Med-Surg proctored Exam review 2021/22 A nurse is contributing to the plan of care for an older adult client who is postoperative following a right ... [Show More] hip arthroplasty. Which of the following interventions should the nurse include in the plan? - Maintain abduction of the right hip. A nurse is caring for a client who has heart failure and respiratory arrest. Which of the following actions should the nurse take first? - Feel for a carotid pulse. 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? - "Bypass surgery must be very frightening for you." 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? - Tell the client to remain in the bathroom after toileting and obtain a wheelchair. 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? - Fully recollapse the reservoir after emptying it. 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? - "I will abstain from sexual intercourse." 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? - Breathe in through her nose and out through pursed lips. 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? - Hypotension 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.) - ✔Decreasing anxiety ✔Controlling emesis ✔Reducing the amount of narcotics needed for pain relief 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? - Iron 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? - Ineffective airway clearance related to thick, copious secretion 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? - Propel a wheelchair equipped with knobs on the wheels. 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? - Sun exposure. 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? - "Do you sleep well at night?" 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? - Fresh berries 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? - Lethargy 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? - "This test will measure the intraocular pressure of the eye." 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 creatinine A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect? - Drop in systolic BP more than 10 mm Hg on inspiration 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? - Attempt to determine what the client was looking for. 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? - Check pedal pulses every 15 min. 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? - The composition of the influenza vaccine changes yearly. 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? - Help the client write down questions to ask his provider. 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? - "It must be hard to see your mother so ill and upset." 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? - Forgetfulness gradually progressing to disorientation 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? - Monitor client's cardinal fields of vision. 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? - Monitor platelet levels 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? - Chest x-ray 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? - Urine output 650 mL/hr 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? - "I took my metformin before breakfast." 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? - Expiratory wheeze 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? - Don clean gloves to remove the dressing. 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? - Sitting, leaning forward over the bedside table. 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? - Denial 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? - Place the client in a high Fowler's position. 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? - Body weight 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? - Hypotension 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? - A sensory warning that a seizure is imminent 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? - "I need something for the horrible pain in my eye." 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? - "You may feel some cramping during the procedure." 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? - Checking pupillary responses to light 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? - Reducing anxiety A nurse is collecting data on a client who has hyperthyroidism. Which of the following manifestations should the nurse expect the client to report? - Frequent mood changes 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? - Fever 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.) - ✔Blurry vision ✔Tachycardia ✔Sweating - symptoms of hyperglycemia - ✔polyphagia ✔polyuria ✔polydipsia [Show Less]
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ATI RN Medical-Surgical Proctored Focus-163 terms 100% CORRECT(ASSURED HIGH SCORING GRADES) A+
ATI RN Medical-Surgical Proctored Focus EGD positioning - left side lying Before an EGD: - -NPO 6-8 hr -remove dentures Gastroenteritis care plan... [Show More] : - -restrict dairy, caffeine, milk -eat foods high in potassium -increase fluid intake -contact precautions In what order do you open the sterile package? - flap furthest from body, side flaps, then closest A nurse has removed a sterile pack from its outside cover and place it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first: A. closest to body B. right side C. left side D. farthest from body - D A nurse is wearing sterile gloves in prep for performing a sterile procedure. Which of the following objects can the nurse tough without breaking sterile technique (Select all that apply) A. bottle containing sterile solution B. edge of sterile drape at the base of the field C. inner wrapping of an item on the sterile field D. irrigation syringe on the sterile field E. one gloved hand with the other gloved hand - C, D, E A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the field (Select all that apply) A. provider drops a sterile instrument onto the near side of the sterile field B. nurse moistens a cotton ball with sterile normal saline and places it on sterile field C. procedure is delayed 1hr because the provider receives an emergency call D. nurse turns to speak to someone who enters through the door behind the nurse E. clients hand brushes against the outer edge of the sterile field - B, C, D TB is suspected, what to do? - -negative airflow room, airborne precautions -nurses wear N95 mask, client wears if going out of the room -admin heat & humidified O2 therapy as prescribed TB interventions: - -family members should be screened -4 meds taken for 6-12 months -not contagious when they have 3 negative sputum cultures What to watch for when on Isoniazid: - numb/tingling in the hands & feet What to watch for when on Rifampin: - -orange secretions normal -watch for jaundice -interferes with birth control What to watch for when on Ethambutol: - vision changes Client teaching for genital herpes: - -can be transmitted with or w/out blisters -sexual partners should be informed & screened -no cure, just meds to help w/symptoms -abstain from intercourse until lesions are completely healed -gently clean areas w/mild soap & water Caring for a client following a stroke of the right side with left-sided hemipalegia: - -thicken liquids/foods -high fowlers -speech therapist for helping w/eating & speech -monitor gag reflex/swallowing abilities -have suction equipment available -occupational therapy -support left arm with pillows, slings, etc High sodium foods clients with HF & Pulmonary edema should avoid: - -cheese -soups -bread -cold cuts/cured meats -pizza -eggs & omelets -hot dogs -baked ham Which non-opioid drug decreases the effect of aspirin? - ibuprofen Ketorolac should not be used concurrently with... - other NSAIDS Glucocorticoids increase the risk of gastric bleeding when taken with... - non-opioid analgesics To access an implanted port, you must use a... - noncoring (Huber) needle When done accessing an implanted port... - flush with 10 mL 0.9% sodium chloride Therapeutic effects of Furosemide - -decreases preload of the heart -decreases potassium levels -increases urine output -decrease BP -decrease edema Valsartan for HF expected outcomes/findings: - -vasodilation -excretion of sodium & water -reduces BP -reduces risk of mortality in post-MI pts left w/vent dysfunction Expected findings of meds that affect urinary output (diuretics): - -decreased potassium -weight loss -decrease in edema -decreased calcium -increased urine output -decreased BP -decrease in ICP & IOP Client teaching for Nitroglycerin: - 1. stop activity & rest 2. place nitro tab under tongue 3. if pain is unrelieved in 5 min, call 911 or go to ED 4. take 2 or more doses at 5 min intervals -headache is a common side effect of nitro Which foods should the client on Warfarin avoid? - dark leafy green veggies Client teaching for anticoagulant therapy: - -bleeding precautions -no added meds that increase bleeding -on it for 6-8 weeks prior to hematologic dx procedure -must have blood levels checked often -monitor vitamin K in their diet Expected prescriptions for Hypertension: - -furosemide -aldactone -hydrochlorothiazide -verapamil -dilitiazem -captopril, lisinopril -losartan, telmisartan -eplerenone -atenolol -metoprolol -clonidine -prazosin (minipress) Contraindications for Nadolol: - -asthma -sinus bradycardia -cardiogenic shock -cardiac failure -diabetes -pregnancy -right side HF -emphysema -severe COPD Treatment for diabetes insipidus: - -daily weights -no caffeine or alcohol -desmopressin acetate/DDVAP -aqueous vasopressin/Pitressin -carbamazepine (tegretol) -high fiber diet Meds for DI, what to look out for/do: - -adjust based on urine output -daily weights -inform of weight gain of 2 lb in 24 hr -notify if headaches or confusion occur -monitor for infection -monitor for dizziness/drowsiness Protein requirement of an adult: _____g of protein per kg - 0.8 g Caring for a client who has pancreatitis: - -keep NPO -NG tube to suction gastric contents -low fat, high protein, high carb diet Risk factors: -high fat diet -excessive alcohol consumption -age Expected lab findings for a client with pancreatitis: - -increased amylase & lipase -increased WBC -decreased platelets -increased glucose -increased liver enzymes & bilirubin -elevated ESR -decreased calcium & magnesium What med do you give for symptomatic bradycardia? What electrical management? - med=atropine elec= pacemaker insertion [Show Less]
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MedSurg 2021/22 proctored ATI- 133 QUESTIONS WITH 100% CORRECT ANSWERS (A+)
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 ... [Show More] the teaching? - Take temperature once a day 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? - Provide humidified oxygen 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? - Obtain a pair of slipper socks for the client 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? - Thick, red-colored urine 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? - Shivering 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? - "I will not exercise if my urine is positive for ketones." 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? - Cover the client's wound with a moist, sterile dressing 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? - Hyperventilation A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching? - Avoid bending at the waist 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? - Check the client's vital signs 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? - Purulent 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? - Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.) - Dyspnea, Barrel chest, Clubbing of the fingers, Shallow respirations 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? - Test the drainage for glucose 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? - Prevent bladder distention 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? - Abnormal vaginal bleeding 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? - Altered level of consciousness 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? - Abdomen is distended 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? - Change the ostomy pouch daily 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? - Change the nasal drip pad as needed 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? - To prevent blood clotting A nurse is collecting data from a client who has open-angle glaucoma. Which of the following findings should the nurse expect? - Loss of peripheral vision 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? - Potassium 2.5 mEq/L 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? - "I will take a tub bath instead of a shower." 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? - Ensure the client's weights are hanging freely from the bed 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? - Take this medication between meals 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? - Take this medication between meals 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? - Wash daily with an antibacterial soap 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? - Avoid medications in capsule or enteric form. 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? - "Large incisions will be made in the burned tissue to improve circulation." 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? - Decreased color perception 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? - Maintain the client in Fowler's position 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.) - Buffalo hump, Purple striations, Moon face 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? - Monitor intake and output hourly 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? - "You will remain NPO for 8 hours before the procedure." 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? - Postictal phase 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? - "The pain will dissipate if you ambulate frequently." 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? - Notify the provider 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.) - Encourage fluid intake, Monitor the puncture site for hematoma 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? - Prevent aspiration A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect? - Hardened skin 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? - Add thickener to fluids 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? - Airway obstruction 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? - Take the medication 45 minutes before eating 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? - Determine the patency of the tubing 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? - "The biopsy can be uncomfortable, but we will try to keep you as comfortable as possible." 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? - Re-establish communication 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? - Hypotension 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: pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Oxygen saturation 80% Bicarbonate 28 mEq/L Which of the following interpretations of the ABG values should the nurse make - Respiratory acidosis 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? - "I will wear stockings with elastic tops." 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? - Calmly ask the client if he would like to listen to some music 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? - Granulation tissue 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? - Fresh fruit basket 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? - Maintain abduction of the right hip. A nurse is caring for a client who has heart failure and respiratory arrest. Which of the following actions should the nurse take first? - Feel for a carotid pulse 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? - "Bypass surgery must be very frightening for you." [Show Less]
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ATI Med surg proctored exam LATEST 2022-75 QUESTIONS WITH 100% CORRECT ANSWERS
Med surg proctored exam 2022 A nurse is assisting with he care of a client following a left femoral cardiac angiography. Thee nurse should place a sandb... [Show More] ag on the client over which of the following areas? - left groin A nurse is reviewing the lab results of a client who is postoperative and has a respiratory rate of 7/min. The arterial blood gas ABG values include: pH 7.22 PaCO2 68 mm Hg base excess -2 PaO2 78 mm Hg oxygen saturation 80% Bicarbonate 28 mEq/L. - respiratory acidosis 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? - I will abstain from sexual intercourse 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? - cover the clients wound with a moist sterile dressing Based on a clients 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? - Do you sleep well at night A nurse collecting data from a client who has manifestations of appendicitis. Where should the nurse palpate to monitor for pain at Mcburneys point? - Mcburneys point is found between the naval and the anterior iliac crest (left lower) A nurse is reinforcing teaching about excercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? - I should avoid injecting insulin into my thigh if I am going to go running A nurse is caring for a client who is postoperative following a tracheostomy and has copies and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin the clients secretions? - provide humidified oxygen A nurse is reviewing the lab results of a client who is taking cyclosporine following a kidney transplant. Which of the following lab findings should the nurse identify as the most important to report to the provider? - increase in serum creatinine 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? - breath in through nose and out through pursed lips 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 clients mobility? - propel a wheelchair equipped with knobs on the wheels A nurse is reinforcing teaching about an esophagogastrodudenscopy with a client who has upper gastric pain. Which of the following statements should the nurse include in the teaching? - you will remain NPO for 8 hours before the procedure A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect? - drop is systolic BP more than 10 mm Hg on inspiration 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 section. Which of the following is the priority finding the nurse should report to the provider? - abdomen is distended 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? - avoid medications in a capsule or enteric form A nurse is caring for a client after a radical dissection. To which of the following should the nurse give priority in the immediate postoperative period? - ineffective airway clearance related to thick copious secretions 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? - Bypass surgery must be very frightening for you 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? - hypotension A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? - dyspnea, barrel chest, clubbing of the fingers, shallow respirations A nurse is assisting with thee 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? - fully recollapse the reservoir after emptying it A nurse is caring for a Client who has Alzheimers disease. The nurse discovers the client entering the room of another client who comes upset and frightened. Which of the following actions should the nurse take? - attempt to determine what the client was looking for 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? - this test will measure the intraocular pressure of the eye A nurse is collecting data from a client who has open angle glaucoma. Which of the following findings should the nurse expect? - loss of peripheral vision A nurse in a providers 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? - take this medication between meals A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect? - hardened skin [Show Less]
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Medical Surgical Proctored ATI Exam A 2021/22-63 QUSTIONS WITH 100% CORRECT ANSWERS(A++)
Medical Surgical Proctored ATI Exam A A nurse is caring for a client who has pancreatitis. The nurse should expect which of the following lab results to... [Show More] be BELOW the expected reference range? A. Amylase B. Alkaline phosphatase C. Bilirubin D. Calcium - D. Calcium A client who has pancreatitis is expected to have a DECREASED calcium and magnesium d/t fat necrosis. The other options would all be increased. A nurse is caring for a client who has DKA. Which of the following lab findings should the nurse expect? A. negative urine ketones B. BUN 32 mg/dL C. pH 7.43 D. HCO3 23 mEq/L - B. BUN 32 mg/dL DKA results in osmotic diuresis and subsequent dehydration. The nurse should expect a client who has DKA to have elevated BUN, creatinine, and specific gravity levels resulting from the excess glucose present in the urine. A. DKA causes ketones in the urine and blood. C. You would expect the pH to be <7.35 (because of the production of ketones) D. You would expect HCO3 <15 d/t increased production of ketones causing metabolic acidosis. A nurse is providing d/c instructions to a client who has a partial-thickness burn on the hand. Which of the following instructions should the nurse include? A. Change the dressing q 72 hr. B. Immobilize the hand with a pressure dressing. C. Take pain medication 30 min after changing the dressing. D. Wrap fingers with individual dressings. - D. Wrap the fingers with individual dressings. The nurse should instruct the client to wrap the fingers individually to allow for functional use of the hand while healing occurs. The nurse should also instruct the client to perform range-of-motion exercises to each finger every hour while awake to promote function of the injured hand. A. q 12-24 hr B. With skin grafts, you should elevate and immobilize the graft site with cotton pressure dressings for 3-5 days following the procedure. C. 30 min before dressing change A nurse is planning care for a client who has extensive burn injuries and is immunocompromised. Which of the following precautions should the nurse include in the POC to prevent Pseudomonas aeruginosa infection? A. Encourage the client to eat raw fruits and veggies. B. Avoid placing plants or flowers in the client's room. C. Limit visitors to members of the client's immediate family. D. Wear an N95 respirator mask when providing care to the client. - B. Avoid placing plants or flowers in the client's room. Live plants can harbor P. aeruginosa, and this bacterium can infect burn wounds and cause life-threatening complications. The nurse should ensure no one brings live plants or flowers into the client's room. A. P. aeruginosa can be found in raw fruits and veggies. C. Prohibit visits from those at risk for P. aeruginosa infections (i.e. anyone who is ill, other hospitalized clients, and small children) D. spread by contact not airborne A nurse in an ED is caring for a client who reports v/d for the past 3 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit? A. HR 110/min B. BP 138/90 mmHg C. Urine specific gravity 1.020 D. BUN 15 mg/dL - A. HR 110/min A client who has a 3-day history of vomiting and diarrhea is likely to have fluid volume deficit and an elevated heart rate. B. WNL (would expect hypotension for this client) C. WNL (would expect >1.030 for this client) D. WNL (would expect BUN >20 for this client) A nurse in an ED is reviewing the provider's prescriptions for a client who sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the nurse expect? A. Apply ice to the client's puncture wound. B. Initiate corticosteroid therapy for the client. C. Keep the client's leg above heart level. D. Administer an opioid analgesic to the client. - D. Administer an opioid analgesic to the client. The nurse should expect a prescription for an opioid analgesic to promote comfort following a rattlesnake bite. A. Apply ice for a bite from a black widow to reduce the action of the neurotoxin from the spider. B. Expect a prescription for antihistamines and corticosteroids from bees and wasps. C. Keep the affected extremity AT HEART LEVEL, not above or below it. A nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. Which of the following statements by the client indicates an understanding of the teaching? A. "I should take calcium supplements so the medication will work better in my system." B. "I am taking this medication to increase my energy level." C. "This medication can cause my BP to drop." D. "I will not need to restrict protein in my diet while taking this medication." - B. "I am taking this medication to increase my energy level." The goal of erythropoietin therapy is to increase the level of hematocrit in clients who have anemia. When the medication is effective, the client should have a decrease in fatigue and an improvement in activity tolerance. A. A client who has chronic kidney disease should have adequate iron stores for erythropoietin therapy to be effective. Clients are encouraged to consume foods high in iron such as beef, liver, pork, and veal. C. Increased RBC productions, leading to HYPERtension D. Does not affect the client's protein requirements A nurse is reviewing the lab results of a client who has cirrhosis. Which of the following lab values should the nurse expect? A. decreased prothrombin time B. elevated bilirubin level C. decreased ammonia level D. elevated albumin level - B. elevated bilirubin level Bilirubin levels reflect the liver's ability to conjugate and excrete bilirubin, a byproduct of the hemolysis of red blood cells. Bilirubin levels rise with liver disease and clinically reflect the client's degree of jaundice. A. Liver disease and severe liver cell damage causes the liver cells to produce less prothrombin, which prolongs prothrombin time. C. Expect elevated ammonia levels because the liver converts ammonia to urea. When this is interrupted, ammonia levels rise. D. Albumin is formed in the liver. With an impaired liver function, albumin levels decrease. A nurse in a community clinic is caring for a client who reports an increase in the frequency of migraine headaches. To help reduce the risk for migraine headaches, which of the following foods should the nurse recommend the client to avoid? [Show Less]
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ATI Med surg proctored exam 2022 (NEW!) 100 QUESTIONS WITH 100% CORRECT ANSWERS
ATI Med Surg Proctored A nurse is caring for a client who is receiving chemotherapy and requests information about acupuncture to relieve some of the si... [Show More] de effects. which of the following findings should the nurse identify as a contraindication to receiving this alternative therapy? - Lymphedema A nurse is preparing to administer lactated Ringer's via continuos 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 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 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 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 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 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 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 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 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 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? - 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 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? - A nurse in the emergency department is assessing a client. which of the following actions should the nurse take first? (click on rhe "exhibit" button for additional information about the client - Initiate airborne precautions 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? - Historyof Crohn's disease 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 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 traensfuntion of the unit of packed RBCs 5. Remain with the client for the first 15 to 30 minutes 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 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 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 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 A nurse is assessing a client following extubation from a ventilator.for which of the following findings should the nurse intervene immediately? - Stridor 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 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 A nurse is planning care for a client who has a pulmonary embolism. which of the following interventions should the nurse include? - Initiate a continuos IV heparin infusion 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 [Show Less]
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ATI MED SURG PROCTORED 2021/22-132 Qs&As (100% CORRECT ANSWERS) GUARANTEED A+
ATI MED SURG PROCTORED 2021/22 A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instru... [Show More] ctions 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. - 1 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.. - 1 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. - 2 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 37.5Æ C (99.5Æ F) 3) Thick, red-colored urine 4) Pain level of 4 on a 0 to 10 rating scale - 3 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 - 1 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." - 4 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. - 1 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 - 2 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. - 1 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. - 3 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 - 4 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. - 1 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 - 1 2 3 4 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. - 4 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. - 3 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 - 4 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 37.7Æ C (100Æ C) 3) Muscle spasms 4) Headache - 1 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 - 1 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. - 1 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. - 2 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? 1) To provide analgesia 2) To reduce inflammation 3) To prevent blood clotting 4) To prevent fever - 3 A nurse is collecting data from a client who has open-angle glaucoma. Which of the following findings should the nurse expect? 1) Loss of peripheral vision 2) Headache 3) Halos around lights 4) Discomfort in the eyes - 1 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 - 3 [Show Less]
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Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems 11th Ed TESTBANK
Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems 11th Edition TESTBANK Table of Contents Section One – Concepts in N... [Show More] ursing Practice 1. Professional Nursing 2. Health Equity and Culturally Competent Care 3. Health History and Physical Examination 4. Patient and Caregiver Teaching 5. Chronic Illness and Older Adults Section Two – Problems Related to Comfort and Coping 6. Stress Management 7. Sleep and Sleep Disorders 8. Pain 9. Palliative and End-of-Life Care 10. Substance Use Disorders Section Three – Problems Related to Homeostasis and Protection 11. Inflammation and Healing 12. Genetics 13. Immune Responses and Transplantation 14. Infection 15. Cancer 16. Fluid, Electrolyte, and Acid-Base Imbalances Section Four – Perioperative Care 17. Management: Preoperative Care 18. Management: Intraoperative Care 19. Management: Postoperative Care Section Five – Problems Related to Altered Sensory Input 20. Assessment and Management: Visual Problems 21. Assessment and Management: Auditory Problems 22. Assessment: Integumentary System 23. Management: Integumentary Problems 24. Management: Burns Section Six – Problems of Oxygenation: Ventilation 25. Assessment: Respiratory System 26. Management: Upper Respiratory Problems 27. Management: Lower Respiratory Problems 28. Management: Obstructive Pulmonary Diseases Section Seven – Problems of Oxygenation: Transport 29. Assessment: Hematologic System 30. Management: Hematologic Problems Section Eight – Problems of Oxygenation: Perfusion 31. Assessment: Cardiovascular System 32. Management: Hypertension 33. Management: Coronary Artery Disease and Acute Coronary Syndrome 34. Management: Heart Failure 35. Management: Dysrhythmias 36. Management: Inflammatory and Structural Heart Disorders 37. Management: Vascular Disorders Section Nine – Problems of Ingestion, Digestion, Absorption, and Elimination 38. Assessment: Gastrointestinal System 39. Management: Nutritional Problems 40. Management: Obesity 41. Management: Upper Gastrointestinal Problems 42. Management: Lower Gastrointestinal Problems 43. Management: Liver, Biliary Tract, Pancreas Section Ten – Problems of Urinary Function 44. Assessment: Urinary System 45. Management: Renal and Urologic Problems 46. Management: Acute Renal Failure and Chronic Kidney Disease Section Eleven – Problems Related to Regulatory and Reproductive Mechanisms 47. Assessment: Endocrine System 48. Management: Diabetes Mellitus 49. Management: Endocrine Problems 50. Assessment: Reproductive System 51. Management: Breast Disorders 52. Management: Sexually Transmitted Infections 53. Management: Female Reproductive Problems 54. Management: Male Reproductive Problems Section Twelve – Problems Related to Movement and Coordination 55. Assessment: Nervous System 56. Management: Acute Intracranial Problems 57. Management: Stroke 58. Management: Chronic Neurologic Problems 59. Management: Alzheimer’s Disease and Dementia 60. Management: Peripheral Nerve and Spinal Cord Problems 61. Assessment: Musculoskeletal System 62. Management: Musculoskeletal Trauma and Orthopedic Surgery 63. Management: Musculoskeletal Problems 64. Management: Arthritis and Connective Tissue Diseases Section Thirteen – Nursing Care in Specialized Settings 65. Management: Critical Care 66. Management: Shock, Systemic Inflammatory Response Syndrome, and Multiple Organ Dysfunction Syndrome 67. Management: Respiratory Failure and Acute Respiratory Distress Syndrome 68. Management: Emergency Care Situations [Show Less]
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Test_Bank_for_Medical_Surgical_Nursing_7th_Edition_by_Linton UPDATED 2022 COMPLETE
Test_Bank_for_Medical_Surgical_Nursing_7th_Edition_by_Linton
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TESTBANK FOR Lewis: Medical-Surgical Nursing, 10th Edition-UPDATED 2022, COMPLETE CHAPTERS
TESTBANK FOR Lewis: Medical-Surgical Nursing, 10th Edition-UPDATED 2022, COMPLETE CHAPTERS
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Test bank for Medical Surgical Nursing 7th edition by Donna D.Ignatavicius and M.Linda Workman
Test bank for Medical Surgical Nursing 7th edition by Donna D.Ignatavicius and M.Linda Workman
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TESTBANK deWit: Medical-Surgical Nursing: Concepts & Practice, 3rd Edition
deWit: Medical-Surgical Nursing: Concepts & Practice, 3rd Edition TESTBANK
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Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 2022
Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e
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ATI Med-Surg Proctored Exam Review 2022-93 Qs&As(100% CORRECT) GUARANTEED A+
Respiratory Alkalosis S/S - lethargy lightheadedness confusion tachycardia dysrhythmias related to hypokalemia nausea vomiting epigastric pain nu... [Show More] mbness and tingling of the extremities hyperventilation (tachypnea) A nurse is contributing to the plan of care for an older adult client who is at risk for Osteoporosis. Which intervention should the nurse include to prevent bone loss? - Encourage weight bearing exercises (such as walking because it can help maintain bone mass by reducing bone demineralization, thus helping to prevent osteoporosis.) A nurse is caring for a client who has meningococal pneumonia. Which of the following personal protective equipment should the nurse use? - Mask (this disease requires droplet precautions) A nurse is reinforcing teaching with a client who is taking insulin Glargine. What information should the nurse include in the teaching? - This type of insulin should be given at the same time everyday. (It is released over a 24hr period) A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. What statement by the client indicates that they are adhering to the nurse's instructions? - "I don't cross my legs anymore". A nurse is caring for a client who has a methicillin-resistant Staphlococcus aureus (MRSA) infections in a surgical wound. What information should the nurse plan to share with visitors? - Visitors must don a gown & gloves prior to entering the client's room. A nurse is reinforcing teaching with a client who has heart failure and a new prescription for hydrochlorothiazide. What should the client report to the provider? - Onset of nausea A nurse is reinforcing discharge teaching with a client who has hearing loss. What action should the nurse take when communicating with the client? - Rephrase client instructions when not understood. A nurse is caring for a client who is 1 day post operative following a hip arthroplasty. The client is exhibiting hypotension, tachycardia, & tacky-nearly. The nurse should recognize these findings as what complication? - Pulmonary Embolism A nurse is monitoring a client who recently had a cast placed on the right lower extremity for a bone fracture. What finding should the nurse recognize as abnormal? - Lack of sensation between the first and second toes A nurse reinforcing teaching with a client who has systemic lupus erythematosus (SLE) and is to begin taking methylprednisolone orally. What should the nurse include in the teaching? - Limit contact with large groups of people A nurse is caring for a client who is 24hr postoperative following abdominal surgery & has an NG tube. What action should the nurse plan to take to decrease the risk of postoperative complications? - Encourage the client to use an incentive spirometer every hour while awake A nurse is collecting data from a client who has chronic kidney disease with hyperkalemia. What finding should the nurse expect related to hyperkalemia? - Bradycardia A nurse is assisting in the care of a client who has manifestations of sepsis. What provider prescriptions should the nurse implement first? - 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." What response should the nurse make? - "Tell me more about the way you are feeling." A nurse is collecting data from a client who has hypokalemia. What finding should the nurse identify as the priority? - Dysrhythmia A nurse is caring for a client who is in Buck's traction. What intervention should the nurse perform to reduce skin breakdown? - Keep the skin dry and free of perspiration 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. What action should the nurse take? - Have a designated stethoscope in the client's room 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. What action should the nurse perform first? - Stop the infusion 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 what? - Hyperactive bowel sounds A nurse is preparing to administer furosemide to a client who has heart failure. What should the nurse report before administering the medication? - Decreased potassium A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis. What information should the nurse include in the teaching? - Apply cold packs to the joints A nurse is collecting data from a client who has hypothyroidism. What manifestation should the nurse expect? - Bradycardia A nurse is reinforcing teaching with an older adult client who has osteoporosis. What instructions should the nurse include in the teaching? - Take the calcium supplements with meals A nurse is reviewing the medical record for an older adult client who is experiencing nausea & vomiting. Based on the client data, what action should the nurse take? (Na 142 mEq, K+ 4.2 mEq/L, BUN 36 mg/dL, Creatinine 1.4 mg/dL) - Notify the charge nurse of the client's BUN level A nurse is admitting a client who is suspected having active tuberculosis (TB). What action should should the nurse take first? - Institute airborne precautions A nurse is monitoring a client who has a wrist cast and reports intense itching underneath the cast. What action should the nurse take? - Blow cool air into the cast using a blow dryer on a cool setting A nurse is planning care for a group of clients after receiving change-of-shift report. What client should the nurse see first? - A client who is dehydrated, has mental confusion, & was found getting out of bed several times during the night. A nurse is caring for a client who reports shortness of breath and has an oxygen saturation of 90%. What action should the nurse take? - Administer oxygen via nasal cannula A nurse is caring for a client who has a prescription for digoxin 0.25mg PO daily. While taking the client's apical pulse, the nurse notes a rate of 58/ min. What action should the nurse take? - Withhold the dose A nurse is caring for a client who has an intestinal obstruction & reports a new onset of nausea. The client has an NG tube set at low intermittent suction & is receiving continuous IV infusion of 0.9% sodium chloride. What action should the nurse take first? - Check for kinks in the NG tube A nurse is reinforcing teaching with a client who is postoperative following a cemented total hip arthroplasty. What instructions should the nurse include in the teaching? - Maintain hip flex ion to 90 or less when sitting A nurse is caring for a client who is 24hr postoperative following an abdominal surgery. What finding requires immediate attention from the nurse? - Oxygen saturation of 88% A nurse is caring for a client following a gastrectomy. What action should the nurse take to decrease episodes of dumping syndrome? - Place the client in the supine position after meals [Show Less]
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MED SURG ATI PROCTORED EXAM-100 Q$As updated 2022(100% correct answers) guaranteed A+
A nurse in an emergency department is preparing to perform an ocular irrigation for a client. Which of the following actions should the nurse plan to take?... [Show More] a. Assess the client's visual acuity prior to irrigation b. Have the client turn their head toward the unaffected eye c. Hold the irrigator syringe 3.81 cm (1.5 in) above the eye d. Perform the irrigation with sterile water for irrigation - d. Perform the irrigation with sterile water for irrigation 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 pump to administer? Round to near whole number - 33 gtt/min 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? a. I can keep my medications for 1 year before replacing it b. I should lie down when I take this medication c. I should discontinue this medication if I develop a headache d. I can take up to five tablets in 15 minutes before seeking medical attention - b. I should lie down when I take this medication A nurse is providing discharge teaching to an older adult client following a left total hip arthroplasty. Which of the following instructions should the nurse include in the teaching? a. Clean the incision daily with hydrogen peroxide b. You can cross your legs the ankles when sitting down c. You should use an incentive spirometer every 8 hours d. Install a raised toilet seat in your bathroom - d. Install a raised toilet seat in your bathroom A nurse is planning care for a client following a cardiac catheterization. Which of the following actions should the nurse take? a. Keep the client on bed rest for 24 hours b. Limit the client's fluid intake to 1 l per day c. Maintain the client's affected extremity in extension d. Change the client's dressing every 8 hour - c. Maintain the client's affected extremity in extension 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? a. I will need to have my partner take over shopping for groceries and cooking the meals for us b. These crutches will make it impossible to care for my child c. I feel bad that I have to ask my partner to keep the house clean d. Its going to be difficult to tell my parents I cant take them to their appointments anymore - a. I will need to have my partner take over shopping for groceries and cooking the meals for us A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration? a. Pitting, dependent edema b. Distended jugular veins c. Increased BP d. Decreased BP - d. Decreased BP A nurse is caring for a client who has a contusion of the brainstem and reports thirst. The client's urinary output was 4,000 ml over the past 24 hour. The nurse should anticipate a prescription for which of the following IV medication? a. Desmopressin b. Epinephrine c. Furosemide d. Nitroprusside - a. Desmopressin A nurse in a clinic receives a phone call from a client who recently started therapy with an ACE inhibitor and reports a nagging dry cough. Which of the following responses by the nurse is appropriate? a. "your cough may require that you stop or change your medication" b. "Increasing your daily fluid intake may eliminate your cough" c. "sucking on lozenge may reduce the frequency of your cough" d. You cough should go away in time" - a. "your cough may require that you stop or change your medication" 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 potential trigger for exacerbations of Raynaud's? a. Eating a strict vegetarian diet b. A history of herpes zoster c. Taking amiodipine for hypertension d. Using a nicotine transdermal patch - d. Using a nicotine transdermal patch A nurse is caring for a client who has a central venous access device and notes the tubing has become disconnected. The client develops dyspnea and tachycardia. Which of the following actions should the nurse take first? a. Perform an ECG b. Obtain ABG values c. Turn the client to his left side d. Clamp the catheter - d. Clamp the catheter A nurse is completing an assessment of an older adult 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? a. Turn and reposition the client every 4 hr b. Apply an occlusive dressing c. Support bony prominences with pillows d. Massage the reddened areas three times a day - c. Support bony prominences with pillows 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? a. Discuss recommendations for eating and swallowing techniques b. List strategies for family coping when dealing with possible role changes c. Review the use of adaptive grooming devices to promote client independence d. Give the client information about the local national multiple sclerosis society - a. Discuss recommendations for eating and swallowing techniques A nurse in the emergency department is assessing a client. Which of the following actions should the nurse take first? Exhibit a. Obtain a sputum sample for culture b. Administer ondansetron c. Initiate airborne precautions d. Prepare the client for a chest x-ray - c. Initiate airborne precautions A nurse is reviewing the medical record of a client to identify risk factors for colorectal cancer. The nurse should identify which of the following findings as increasing the client's risk? a. History of Crohn's disease b. BMI of 24 c. Diet high in fiber d. Age 46 years - a. History of Crohn's disease 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? a. "I can give you a list of other people who had the same procedure" b. "You will be cancer-free if you have the procedure" c. "I can give you additional information about the procedure" d. "You should should get a second opinion regarding the procedure" - c. "I can give you additional information about the procedure" 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. e. Remain with the client for the first 15 to 30 min of the infusion a. Obtain venous access using 19-gauge needle c. Verify blood compatibility with another nurse d. Initiate transfusion of the unit of packed RBCs b. Obtain the unit of packed RBCs from blood bank - a. Obtain venous access using 19-gauge needle b. Obtain the unit of packed RBCs from blood bank c. Verify blood compatibility with another nurse d. Initiate transfusion of the unit of packed RBCs e. Remain with the client for the first 15 to 30 min of the infusion A nurse is preparing a teaching plan for a client who has mucositis related to chemotherapy treatment. Which of the following instructions should the nurse include? a. "rinse your mouth with hydrogen peroxide" b. "brush your teeth for 60 seconds twice daily" c. "wear your dentures only during meals" d. "floss your teeth following each meals" - d. "floss your teeth following each meals" A critical care nurse is assessing a client who has 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? a. 5 b. 2 c. 13 d. 10 - a. 5 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? a. "I can season my foods with garlic and onion salts" b. "I can have mayonnaise on my sandwiches" c. "I can have a frozen fruit juice bar for dessert" d. "I can drink vegetable juice with a meal" - c. "I can have a frozen fruit juice bar for dessert" A nurse is preparing to perform ocular irrigation for a client following chemical splash to the eye. Which of the following actions should the nurse plan to take first? a. Instill 0.9% sodium chloride solution into the affected eye b. Administer proparacaine eyedrops into the affected eye c. Collect information about the irritant that caused the injury - c. Collect information about the irritant that caused the injury A nurse is assessing a client following extubation from a ventilator. For which of the following findings should the nurse intervene immediately? a. Rhonchi b. SaO2 92% c. Sore throat d. Stridor - d. Stridor A nurse is reviewing the laboratory reports of a client who has acute pancreatitis. Which of the following findings should the nurse expect? a. Elevated serum calcium b. Elevated blood glucose c. Decreased serum amylase d. Decreased erythrocyte sedimentation rate - b. Elevated blood glucose A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of the following findings should the nurse expect? a. Hypothermia b. Urine specific gravity 1.001 (<1.005) c. Elevated blood pressure d. BUN 15 mg/dl - b. Urine specific gravity 1.001 (<1.005) [Show Less]
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ATI Med surg proctored exam 2022 (NEW!) 75 QUESTIONS WITH 100% CORRECT ANSWERS
ATI Med surg proctored exam 2022 (NEW!) 75 QUESTIONS WITH 100% CORRECT ANSWERS 1. A nurse is assisting with he care of a client following a left femoral c... [Show More] ardiac angiography. Thee nurse should place a sandbag on the client over which of the following areas? - 2. A nurse is reviewing the lab results of a client who is postoperative and has a respiratory rate of 7/min. The arterial blood gas ABG values include: 3. 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? - 4. 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? - 5. Based on a clients 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? - 6. A nurse collecting data from a client who has manifestations of appendicitis. Where should the nurse palpate to monitor for pain at Mcburneys point? - 7. A nurse is reinforcing teaching about excercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? - I 8. A nurse is caring for a client who is postoperative following a tracheostomy and has copies and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin the clients secretions? - 9. A nurse is reviewing the lab results of a client who is taking cyclosporine following a kidney transplant. Which of the following lab findings should the nurse identify as the most important to report to the provider? - 10. 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? - 11. 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 clients mobility? - 12. A nurse is reinforcing teaching about an esophagogastrodudenscopy with a client who has upper gastric pain. Which of the following statements should the nurse include in the teaching? - 13. A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect? - 14. 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 section. Which of the following is the priority finding the nurse should report to the provider? - 15. 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? - 16. A nurse is caring for a client after a radical dissection. To which of the following should the nurse give priority in the immediate postoperative period? - 17. 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? - 18. 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? - 19. A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? - 20. A nurse is assisting with thee 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? - 21. A nurse is caring for a Client who has Alzheimers disease. The nurse discovers the client entering the room of another client who comes upset and frightened. Which of the following actions should the nurse take? - 22. 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? - 23. A nurse is collecting data from a client who has open angle glaucoma. Which of the following findings should the nurse expect? - 24. A nurse in a providers 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? - 25. A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect? - 26. A nurse is checking the suction control chamber of a clients chest tube and notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? - 27. 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 thee biopsy will hurt. Which of the following responses should the nurse make? - 28. A nurse is assisting in the plan of care for a client who had removal if the pituitary gland. Which of the following actions should the nurse include in the plan? - 29. 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? - 30. 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? - 31. A nurse is caring for a client who has a temp of 103.5 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? - 32. A nurse is reinforcing preop teaching for a client who is scheduled for surgery and is to take hydroxyzine preop. Which of the following effects of the medication should the nurse include in the teaching? - 33. A nurse is collecting data from a client who has acute gastroenteeritis. Which of the following data collection findings should the nurse identify as the priority? - 34. A nurse is caring for a client who is being evaluated for endometerial cancer. Which of the following findings should the nurse expect the client to report? - 35. A nurse is reinforcing teaching with a client who has a new presicprion for epoetin alfa. The nurse should reinforce to the client to take which of the following dietary supplements with this medication? - 36. A nurse is caring for an older adult client who has dysphasia and left sided weakness following a stroke. Which of the following actions should the nurse take? - 37. A nurse is caring or 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? - 38. A nurse is caring for a client who asks why she is being preceived aspirin 325 mg daily following a MI. The nurse should instruct the client that aspirin is prescribed for clients who have coronary artery disease for which of the following effects? - 39. A nurse is caring for a client who has a spinal cord injury at T4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of thee following interventions should thee nurse take to prevent autonomic dysreflexia? - 40. 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 a 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? - 41. A nurse is caring for a client who is difficult to arrouse and very sleepy for several hours following a general tonic clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record? - 42. 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? - 43. A nurse is collecting data on a clients 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? - 44. 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? - 45. 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? - 46. 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? - 47. A nurse is preparing to provide morning hygiene care for a client who has Alzheimers disease. The client becomes agitated and combative when the nurse approaches him. Which of the following actions should the nurse plan to take? - 48. A nurse is contributing to the plan of care for an older adult client who is postoperative following a right hip athroplasty. Which of the following interventions should the nurse include in the plan? - 49. A nurse is caring for a client who is postoperative and has a history of Addisons disease. For which of the following manifestations should the nurse monitor? - 50. A nurse is assisting with caring for a client who has a new concussion following a MVC. The nurse should monitor the client for which of the following manifestations of the increased IP? - 51. 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? - 52. A nurse is caring for a client who has heart failure and respiratory arrest. Which of the following actions should the nurse take first? - 53. 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 comfort? - 54. A nurse is minoring the client peripheral circulation. Identify where the nurse should palpate to check the posterior tibial pulse. - 55. A nurse is caring or a client following an open reduction and internal fixation of a fractured femur. Which of the following findings is the nurses priority? - 56. 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? - 57. 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? 58. A nurse is assisting with the care of a client who is postoperative following a surgical repair of a fractured mandible. The clients jaw is wired shut to repair and stabilize the fracture. The nurse should recognize which of the following is the priority action? - 59. 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? - 60. A nurse is caring for a client who is 4 hr postoperative following a TIRP. Which of the following is the priority for the nurse to report to the provider? - 61. 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? - 62. 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 out of the clients right nostril. Which of the following actions should the nurse take first? - 63. 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? - 64. 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? - 65. A nurse is caring for a client who has Cushings syndrome. Which of the following clinical manifestations should the nurse expect to observe? - 66. A nurse is reinforcing teaching with a client who is newly diagnoses with myasthenia gravis and is to start taking neostigmine. Which of the following instructions should the nurse include in the teaching? - 67. 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? - 68. A nurse is caring for a client who 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? - 69. A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? - 70. A nurse is caring for a client who is 3 days postoperative following a cholescytectomy. The nurse suspects the clients 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? - 71. 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? - 72. A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent psotop complications which of the following actions should be reinforced during the teaching? - 73. A nurse is reinforcing teaching with a client who has PVD. The nurse should recognize that which of the following statements by the client indicates a need for further teaching? 74. A nurse is reinforcing teaching with a client who reports right shoulder pain following a laproscopic cholescystecomty. Which of the following statements should the nurse make? - 75. A nurse is reinforcing teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching? - [Show Less]
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Test Bank - Brunner Suddarth’s Textbook of Medical-Surgical Nursing by Janice L. Hinkle, 2022
Test Bank - Brunner Suddarth’s Textbook of Medical-Surgical Nursing by Janice L. Hinkle, PhD, RN, CNRN Kerry H. Cheever, PhD, RN
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Targeted Med-Surg Practice Assessment 2021/22 (ALL ANSWERS ARE 100% CORRECT)
A nurse is caring for a client who has acute respiratory failure. What lab findings should the nurse expect? - PaO2 58mmHg Rat.: nurse should expect to ... [Show More] find a low partial pressures of oxygen for a patient who has acute resp. failure A nurse is assessing a client who has emphysema. Which of the following findings should the nurse report to the provider? - Elevated temp. Rat.: clients who have emphysema are at risk for the development of pneumonia and other resp. infections. A nurse should report this as it indicates a possible resp. infection. A nurse is caring for a client who is postop and has a respiratory rate of 9/min secondary to general anesthesia effects and incisional pain. What ABG values support the nurses suspicion of respiratory acidosis? - pH 7.30, PO2 80mmHg, PaCO2 55mmHg, HCO3 22mEq/L Rat.: The pH is less than 7.35 and PaCO2 is greater than 45mmHg, which indicates resp. acidosis. A nurse is positioning a client who has emphysema to promote effective breathing. The nurse should place the client in what position? - High fowlers position with arms supported on the overbed table. Rat.: The nurse should place the client in a position that allows for greater expansion of the chest. A nurse is providing discharge teaching to a client who has pulmonary TB and a new prescription for rifampin. Which of the following instructions should the nurse include? - "Expect your urine and other secretions to be orange while taking this medication." A nurse working in th ER is caring for a client following an acute chest trauma. Which of the following findings indicates tot he nurse the client is possibly experiencing a tension pneumothorax? - Tracheal deviation to the unaffected side. Rat.: a tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side A nurse is caring for a client who has COPD. What findings should the nurse report to the provider? - Productive cough with green sputum Rat.: A nurse should report this as it indicates an infection A nurse is assisting with a thoracentesis. What actions is appropriate for the nurse to take when assisting with this procedure? - -Wear goggles and mask during the procedure: should wear this to reduce the risk of exposure to pleural fluid. -Cleanse the area with an antiseptic solution: this decreases the risk of infection, which is increased due to the invasive procedure. -Apply pressure to the site after the needle is withdrawn: this decreases the risk of bleeding at the needle insertion site A nurse is caring for a client who has pulmonary embolism. Which of the following interventions is the priority? - Administer heparin via continuous IV infusion. Rat.: using the airway, breathing, circulation approach to client care, the nurse should place priority on stabilizing circulation to the lungs by admin. heparin to prevent further clot formation. Therefore, this is the priority intervention. A nurse is caring for a client who has a chest tube following a lobectomy. Which of the following items should the nurse keep easily accessible for the client? - container of sterile water. Rat.: the nurse should plan to place the open end of the tubing if it becomes disconnected into the sterile water to prevent a pneumothroax. The tubing and sterile water are then placed below the clients chest. A nurse is caring for a client who is in respiratory distress. What device should the nurse use to provide the highest level of oxygen via a low-flow system? - Nonrebreather mask Rat.: this mask is made up of a reservoir bag from which the client obtains the oxygen, a one way valve to prevent exhaled air from entering the reservoir bag, and exhalation ports with flaps that prevent room air from entering the mask. This delivers greater than 90% FlO2 which provides the highest level of oxygen. A nurse is caring for four clients. What client is at greatest risk for pulmonary embolism? - A client who is 12hr postop following a total hip arthroplasty Rat.: it is this client due to decreased mobility of the affected extremity. A nurse is planning care for a client who has asthma. Which of the following medications should the nurse plan to administer during an acute asthma attack? - asthma A nurse is caring for a client who is 4hr postop following a total laryngectomy for laryngeal cancer. What assessment is priority? - Oxygen saturation Rat.: Using ABC's approach the nurse should identify the client's oxygen sat is the priority. This client is at risk for hypoxia due to airway obstruction and decreased oxygen sat is an indication of an obstructed airway. A nurse is assessing a client who has a chest tube in place following thoracic surgery. What finding indicates a need for intervention? - Continuous bubbling in the water seal chamber. Rat.: continuous bubbling is the water seal chamber suggests an air leak. A nurse is caring for a client who is experiencing a pulmonary embolism. What actions should the nurse take first? - Apply supplemental oxygen. [Show Less]
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Med-Surg Chapters 59 (54 QUESTIONS WITH 100% CORRECT ANSWERS) 2021/22
1. A client has irritable bowel syndrome. Which menu selections by this client indicate good understanding of dietary teaching? a. Tuna salad on white bre... [Show More] ad, cup of applesauce, glass of diet cola b. Broiled chicken with brown rice, steamed green beans, glass of apple juice c. Grilled cheese sandwich, small ripe banana, cup of hot tea with lemon d. Grilled steak, green beans, dinner roll with butter, cup of coffee with cream - B 2. Clients with irritable bowel syndrome are advised to eat a high-fiber diet (30 to 40 grams a day), with 8 to 10 cups of liquid daily. This selection has the highest fiber content. They should avoid alcohol, caffeine, and other gastric irritants. 3. The nurse is performing a physical examination on a client. Which assessment finding leads the nurse to check the client's abdomen for the presence of an acquired umbilical hernia? a. Body mass index (BMI) of 41.9 b. Cholecystectomy last year c. History of irritable bowel syndrome d. Daily dose of lansoprazole (Prevacid) 30 mg orally - A 4. This type of hernia is associated with obesity. The other assessment findings do not place the client at increased risk for an acquired umbilical hernia. 5. The nurse notes a bulge in a client's groin that is present when the client stands and disappears when the client lies down. Which conclusion does the nurse draw from these assessment findings? a. Reducible inguinal hernia b. Indirect umbilical hernia c. Strangulated ventral hernia d. Incarcerated femoral hernia - A 6. In a reducible hernia, the contents of the hernial sac can be replaced into the abdominal cavity by gentle pressure or by lying flat. The contents of irreducible, strangulated, or incarcerated hernias may not be replaced into the abdomen when the client lies down. 7. The nurse is caring for a client with an umbilical hernia who reports increased abdominal pain, nausea, and vomiting. The nurse notes high-pitched bowel sounds. Which conclusion does the nurse draw from these assessment findings? a. Bowel obstruction; client should be placed on NPO status. b. Perforation of the bowel; client needs emergency surgery. c. Adhesions in the hernia; client needs elective surgery. d. Hernia is dangerously enlarged; client needs a nasogastric (NG) tube. - A 8. The client with a hernia presenting with abdominal pain, fever, tachycardia, nausea and vomiting, and hypoactive bowel sounds should be suspected of having developed strangulation. Strangulation poses a risk of intestinal obstruction. The client should be placed on NPO status, and the health care provider should be notified. The symptoms are not suggestive of enlargement of the hernia, adhesion formation, or bowel perforation. 9. The nurse is teaching a client how to use a truss for a femoral hernia. Which statement by the client indicates the need for further teaching? a. "I will put on the truss before I go to bed each night." b. "I will put some powder under the truss to avoid skin irritation." c. "The truss will help my hernia because I can't have surgery." d. "If I have abdominal pain, I will let my health care provider know right away." - A 10. The client is instructed to apply the truss before arising, not before going to bed at night. The other statements show accurate knowledge in using a truss. 11. The nurse is providing preoperative teaching for a client who will undergo herniorrhaphy surgery. Which instruction does the nurse give to the client? a. "Eat a low-residue diet for the first week after surgery." b. "Change the dressing every day until the staples are removed." c. "Take acetaminophen (Tylenol) 1000 mg every 4 hours for pain." d. "Cough and deep breathe every 2 hours for the first week after surgery." - B 12. The dressing should be changed every day until the staples are removed, so the client can check the incision for signs of infection. Constipation is common following hernia surgery, so clients should include adequate amounts of fiber in the diet. The maximum daily dosage of Tylenol is 4000 mg. Taking 1000 mg of Tylenol every 4 hours means that intake is 6000 mg/day, which could cause toxicity and liver damage. The client should change positions and take deep breaths to facilitate lung expansion but should avoid coughing, which can place stress on the incision line. 13. The nurse is performing a physical assessment for a client who underwent a hemorrhoidectomy the previous day. The nurse notes that the client has lower abdominal distention accompanied by dullness to percussion over the distended area. Which is the nurse's priority action? a. Assess the client's vital signs. b. Determine the last time the client voided. c. Insert a rectal tube to facilitate passage of flatus. d. Document the findings in the client's chart. - B 14. Assessment findings indicate that the client may have an overfull bladder. In the immediate postoperative period, the client may experience difficulty voiding owing to urinary retention. A rectal tube should not be inserted for a client who had a hemorrhoidectomy the previous day. The client's vital signs may be checked after the nurse determines the client's last void. The nurse should document all findings and actions in the client's medical record. 15. The nurse is screening clients at a community health fair. Which client is at highest risk for development of colorectal cancer? a. Young adult who drinks eight cups of coffee every day b. Middle-aged client with a history of irritable bowel syndrome c. Older client with a BMI of 19.2 who works 65 hours per week d. Older client who travels extensively and eats fast food frequently - D 16. Colon cancer is rare before the age of 40, but its incidence increases rapidly with advancing age. Fast food tends to be high in fat and low in fiber, increasing the risk for colon cancer. Irritable bowel syndrome, a heavy workload, and coffee intake do not increase the risk for colon cancer. A BMI of 19.2 is within normal limits. 17. The nurse is performing a physical assessment of a client with a new diagnosis of colorectal cancer. The nurse notes the presence of visible peristaltic waves and, on auscultation, hears high-pitched bowel sounds. Which conclusion does the nurse draw from these findings? a. The tumor has metastasized to the liver and biliary tract. b. The tumor has caused an intussusception of the intestine. c. The growing tumor has caused a partial bowel obstruction. d. The client has developed toxic megacolon from the growing tumor. - C 18. The presence of visible peristaltic waves, accompanied by high-pitched or tingling bowel sounds, is indicative of partial obstruction caused by the tumor. Assessment findings do not indicate metastasis to the liver, intussusception of the intestine, or toxic megacolon. 19. The nurse is caring for a client who is scheduled to have fecal occult blood testing. Which instructions does the nurse give to the client? a. "You must fast for 12 hours before the test." b. "You will be given a cleansing enema the morning of the test." c. "You must avoid eating meat for 48 hours before the test." d. "You will be sedated and will require someone to accompany you home." - C 20. The client is instructed to avoid meat, aspirin, vitamin C, and anti-inflammatory drugs for 48 hours before the test. The other directions are not accurate for this test. [Show Less]
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Medical-Surgical Drugs Questions and Answers (100% CORRECT)
The provider prescribes one unit of packed red blood cells to be administered to a client. To ensure the client's safety, which measure should the nurse t... [Show More] ake during administration of blood products? Correct1 Stay with client during first 15 minutes of infusion. 2 Flush packed red blood cells with 5% dextrose and 0.45% normal saline. 3 Discontinue the intravenous catheter if a blood transfusion reaction occurs. 4 Administer the red blood cells through a percutaneously inserted central catheter line with a 20-gauge needle. The nurse should remain with the client for the first 15 to 30 minutes. Any severe reaction usually occurs with the infusion of the first 50 mL of blood. Blood components are viscous, requiring a large needle to be used for venous access. A 20-gauge needle is not used to access a central catheter line. Normal saline is the solution to administer with blood productions. Lactated Ringer and dextrose in water are not used for infusion because of hemolysis. 75%of students nationwide answered this question correctly. View Topics 3029691363 Confidence: Just a guess Stats Issue with this question? 8.A client who takes daily megadoses of vitamins is hospitalized with joint pain, loss of hair, yellow pigmentation of the skin, and an enlarged liver due to vitamin toxicity. What type of toxicity does the nurse suspect? Correct1 Retinol (vitamin A) 2 Thiamine (vitamin B1) 3 Pyridoxine (vitamin B6) 4 Ascorbic acid (vitamin C) These adaptations, as well as anemia, irritability, pruritus, and an enlarged spleen, occur with vitamin A toxicity. Excess thiamine is excreted in the urine and rarely, if ever, causes toxicity; an excessive dose may elicit an allergic reaction in some individuals. Excess vitamin C (ascorbic acid) does not cause these adaptations or toxicity; however, vitamin C may cause diarrhea or renal calculi. Pyridoxine (vitamin B6) is relatively nontoxic, and excess amounts are excreted in the urine. STUDY TIP: Begin studying by setting goals. Make sure they are realistic. A goal of scoring 100% on all exams is not realistic, but scoring an 85% may be a better goal. 54%of students nationwide answered this question correctly. View Topics 3029538155 Confidence: Just a guess Stats Issue with this question? 10. A client with diabetes asks how exercise will affect insulin and dietary needs. What information does the nurse share about insulin and exercise? Correct1 "Exercise increases the need for carbohydrates and decreases the need for insulin." 2 "Exercise increases the need for insulin and increases the need for carbohydrates."3 "Regular physical activity decreases the need for insulin and decreases the need for carbohydrates." 4 "Intensive physical activity decreases the need for carbohydrates but does not affect the need for insulin." Exercise increases the uptake of glucose by active muscle cells without the need for insulin; carbohydrates are needed to supply energy for the increased metabolic rate associated with exercise. The need for insulin is decreased. Test-Taking Tip: Being emotionally prepared for an examination is key to your success. Proper use of resources over an extended period of time ensures your understanding and increases your confidence about your nursing knowledge. Your lifelong dream of becoming a nurse is now within your reach! You are excited, yet anxious. This feeling is normal. A little anxiety can be good because it increases awareness of reality; but excessive anxiety has the opposite effect, acting as a barrier and keeping you from reaching your goal. Your attitude about yourself and your goals will help keep you focused, adding to your strength and inner conviction to achieve success. 57%of students nationwide answered this question correctly. View Topics 3029539085 Confidence: Just a guess Stats Issue with this question? 12. A client with a new diagnosis of type 1 diabetes is told that lifelong insulin will be needed. The client becomes agitated and says, "I am scared of shots. If that is my only option, I’ll just have to go into a coma and die!" What is the nurse’s best response? Correct1 "Injections are not the only option available for insulin." 2 "It won’t be so bad; you will get used to it if you will only try." 3 "This is one of those times when you need to act like an adult." 4"Clients have the right to refuse treatment, but I need you to sign this form that removes us from liability for your decision." An insulin nasal spray was approved by the Food and Drug Administration (FDA) in 2014 and is available for clients who do not want insulin injections. The nurse should use therapeutic communication in interacting with clients. Intimidating the client by suggesting that actions are childlike and suggesting that the client’s concerns are not significant are not therapeutic responses. The nurse’s primary concern should be for the client’s well-being, not protection from liability. Test-Taking Tip: If you are unable to answer a multiple-choice question immediately, eliminate the alternatives that you know are incorrect and proceed from that point. The same goes for a multipleresponse question that requires you to choose two or more of the given alternatives. If a fill-in-the-blank question poses a problem, read the situation and essential information carefully and then formulate your response. 66%of students nationwide answered this question correctly. View Topics 3142279413 Confidence: Just a guess Stats Issue with this question? 14. A client who is receiving phenytoin to control a seizure disorder questions the nurse regarding this medication after discharge. How will the nurse respond? Correct1 "Antiseizure drugs will probably be continued for life." 2 "Phenytoin prevents any further occurrence of seizures." 3 "This drug needs to be taken during periods of emotional stress." 4 "Your antiseizure drug usually can be stopped after a year's absence of seizures." Seizure disorders usually are associated with marked changes in the electrical activity of the cerebral cortex, requiring prolonged or lifelong therapy. Seizures may occur despite drug therapy; the dosage may need to be adjusted. A therapeutic blood level must be maintained through consistent administration ofthe drug irrespective of emotional stress. Absence of seizures will probably result from medication effectiveness rather than from correction of the pathophysiologic condition. 53%of students nationwide answered this question correctly. View Topics 3029486363 Confidence: Just a guess Stats Issue with this question? 17. A client develops thrombophlebitis in the right calf. Bed rest is prescribed, and an IV of heparin is initiated. What drug action will the nurse include when describing the purpose of this drug to the client? Correct1 Prevents extension of the clot 2 Reduces the size of the thrombus 3 Dissolves the blood clot in the vein 4 Facilitates absorption of red blood cells Heparin interferes with activation of prothrombin to thrombin and inhibits aggregation of platelets. Heparin does not reduce the size of a thrombus. Heparin does not dissolve blood clots in the veins. Heparin does not facilitate the absorption of red blood cells. 60%of students nationwide answered this question correctly. View Topics 3142284896 Confidence: Just a guess Stats Issue with this question? 23.A client reports nausea, vomiting, and seeing a yellow light around objects. A diagnosis of hypokalemia is made. Upon a review of the client's prescribed medication list, the nurse determines that what is the likely cause of the clinical findings? Correct1 Digoxin (Lanoxin) 2 Furosemide (Lasix) 3 Propranolol (Inderal) 4 Spironolactone (Aldactone) These are signs of digitalis toxicity, which is more likely to occur in the presence of hypokalemia. Although furosemide most likely contributed to the hypokalemia, the client's symptoms are consistent with digitalis toxicity. Although propranolol can cause nausea, vomiting, and blurred vision, the presence of hypokalemia and yellow vision are more suggestive of digitalis toxicity. A side effect of spironolactone is hyperkalemia, not hypokalemia. 59%of students nationwide answered this question correctly. A client with cancer of the thyroid is scheduled for a thyroidectomy. What should the nurse teach the client? Incorrect1 The dietary intake of carbohydrates must be restricted. Correct2 Thyroxine replacement therapy will be required indefinitely. 3 Chemotherapy may be used in conjunction with the surgery. 4 A tracheostomy requires an alternative means of communication. Thyroxine is given postoperatively to suppress thyroid-stimulating hormone (TSH) and prevent hypothyroidism. Increased intake of carbohydrates and proteins is needed because of the increased metabolic activity associated with hyperthyroidism. Chemotherapy is uncommon; radiation may be used to eradicate remaining tissue. A tracheostomy is not planned; it is needed only in an emergency related to respiratory distress.Test-Taking Tip: Being prepared reduces your stress or tension level and helps you maintain a positive attitude. 85%of students nationwide answered this question correctly. View Topics 3142284817 Confidence: Just a guess Stats Issue with this question? 2. A client who had abdominal surgery is receiving patient-controlled analgesia intravenously to manage pain. The pump is programmed to deliver a basal dose and bolus doses that can be accessed by the client, with a lock-out time frame of 10 minutes. The nurse assesses use of the pump during the last hour and identifies that the client attempted to self-administer the analgesic 10 times. Further assessment reveals that the client is experiencing pain still. What should the nurse do first? Incorrect1 Monitor the client's pain level for another hour. Correct2 Determine the integrity of the intravenous delivery system. 3 Reprogram the pump to deliver a bolus dose every 8 minutes. 4 Arrange for the client to be evaluated by the healthcare provider. Initially, integrity of the intravenous system should be verified to ensure that the client is receiving medication. The intravenous tubing may be kinked or compressed or the catheter may be dislodged. Continued monitoring will result in the client experiencing unnecessary pain. The nurse may not reprogram the pump to deliver larger or more frequent doses of medication without a healthcare provider's prescription. The healthcare provider should be notified if the system is intact and the client is not obtaining relief from pain. The prescription may have to be revised; the basal dose may be increased, the length of the delay may be reduced, or another medication or mode of delivery may be prescribed. 52%of students nationwide answered this question correctly. [Show Less]
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NURS 002 Capstone focused review ATI MEDSurg
NURSING CARE OF CLIENTS WHO HAVE CARDIOVASCULAR DISORDERS SECTION: VASCULAR DISORDERS CHAPTER 30 Peripheral Vascular Diseases Peripheral vascular dise... [Show More] ases include peripheral arterial disease (PaD) and peripheral venous disorders, both of which interfere with normal blood flow. PaD affects arteries (blood vessels that carry blood away from the heart), and peripheral venous disease affects veins (blood vessels that carry blood toward the heart). Peripheral arterial disease [Show Less]
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Advanced Medsurg Final Exam Questions with 100% CORRECT ANSWERS 2021/22 [NEW]
1. Pt. receiving chemo with acute dehydration (nausea and vomiting), what to do to prevent to Systemic inflammatory response syndrome (SIRS) and Multiple ... [Show More] organ dysfunction syndrome (MODS) – a. place patient in a private room (immunocompromised) 2. When assessing hemodynamic of patient with shock of unknown etiology, don’t give large volumes of crystalloids when – a. CO is high and CVP is low (septic shock) 3. Diabetic patient vomiting and diarrhea for past 3 days, glucose is 748, urine output 120, cyanotic hands and feet– a. progressive stage of hypovolemic shock 4. Industrial acids at work spilled on patient, what to do before transporting to hospital – a. flush burned area with large amounts of tap water 5. 6 hours after thermal burn to arms and legs, important info to tell doctor a. urine output 20-30 ml per hour 6. During early emergent phase of burns – a. give opioid IV so that medications will be rapidly effective 7. Nurse caring for pt. admitted with burns, 30% of body surface recognized, emergent to acute phase – a. pt. has large quantities of pale urine 8. Pt. acute phase of burn injury requires frequent hydrotherapy sessions for wound debridement – a. closely monitor serum sodium level 9. Acute asthma attack, which info indicates pt. requires further teaching – a. pt. has been using Proventil more frequently over the last 4 days 10. Asthma pt. admitted for acute respiratory distress, notify HCP immediately if – a. decreased breath sounds and wheezing 11. Intubation with mechanical ventilation for pt. with status asthmaticus when – a. fatigue and oxygen saturation of 88% develops 12. Asthma pt. has new prescription for Advair and diskus, ask nurse for purpose of 2 drugs – a. one drug decreases inflammation, other is a bronchodilator 13. HCP prescribed MDI q8h Maxair and Symbicort – a. use spacer with MDI 14. Activity intolerance for pt. with asthma – a. work of breathing 15. Finding for acute asthma attack was responding to bronchodilator therapy – a. wheezes are more easily heard 16. Pt. has mild persistent asthma uses Proventil has new prescription for chromolyn – a. use chromolyn for inflammatory airway changes, take several weeks for max effect 17. During assessment of asthma, has wheezing and dyspnea – a. give meds to reduce airway narrowing18. Pt. with acute asthma attack comes to ER, ABG’s are drawn, pH 7.4, co2 32, paO2 70, teach pt use of peak flow meter – a. take something before peak flow readings when asthma attack/symptoms 19. COPD pt. has dyspnea, cough, yellow sputum, upon palpation of thorax expected finding – a. chest expansion is diminished 20. COPD with barrel chest, why – overinflation of the alveoli 21. Pulmonary function test for COPD pt – increased residual volume 22. Chronic hypoxemia 89-90 % caused by COPD, compliance – arrange pt. spouse to be present during teaching 23. 68 YO with COPD, cor pulmonale manifestation – 3+ edema in lower extremities 24. COPD that smokes, tell them that smoking – decreases area available for oxygen absorption 25. Acute COPD exacerbation, ph 7.32 paO2 58, co2 55, pulse ox 86 indicates – respiratory acidosis 26. Imbalanced nutrition less than body requirement intervention – a. offer high calorie snacks between meals and at bedtime 27. COPD, info given by patient that confirms chronic bronchitis – a. productive cough every winter for 2 months 28. Pursed lip breathing purpose – a. preventing airway collapse and trapping air in lung during expiration 29. Impaired gas exchange in COPD with acute respiratory distress – pulse ox 86% 30. COPD with cor pulmonale, assess/monitor for – JVD 31. COPD receiving oxygen – maintain oxygen at 90% or greater 32. COPD ask about home health oxygen use – it can improve pt. long term prognosis and quality of life 33. RN observes students suctioning, when to intervene – clean gloves when using a sterile catheter 34. Pt. coughs violently and dislodges trach tube – insert obturator 35. When inflating cough to appropriate level – use manometer 36. Info in pt with ARDS being treated with PEEP indicates complication – pt. has subcutaneous emphysema 37. PEEP purpose, explains to family – a. PEEP prevents air sacs from collapsing during exhalation 38. Evaluate 02 ventilation for acute respiratory – use ABG 39. Findings for acute respiratory failure – partial pressure of Oxygen at 45 mmhg 40. Caring for patient developed ARDS as a result of a UTI, how it happened? a. – infection caused by generalized inflammation that damaged the lungs 41. When prone position Is used for ARDS, positioning is effective if – patients FIo2 is 90, and o2 stat is 92 42. Nurse obtains vital signs of temp 101, bp 90/56, pulse 92, resp 34, whats next ? – obtain pulse ox43. Monitor for clinical manifestations of hypercapnia when pt. in ER has – a. chest trauma and multiple rib fractures 44. Pt. hypercapnia respiratory failure, resp. 8, pulse ox 89, extremely lethargic – ET with PEEP 45. Protect pt. from aspiration pneumonia – position pt. with altered level of consciousness in lateral position 46. Drug overdose in ER, barbiturates, potential complication– a. hypercapnic respiratory failure related to decreased ventilator effort 47. Pulmonary embolism, how to explain to patient – a. blood flow to some areas of your lungs is decreased even though you’re taking adequate breaths 48. Upper Lobectomy patient complains of incisional pain 7/10, decreased left sided breath sounds, 100 ML of bloody drainage with large air leak, intervention – a. medicate patient with ordered morphine 49. HCP 2 chest tubes with Y-connector in pneumothorax, nurse should be concerned about – a. 400 ml of blood in the collection chamber 50. Pt has right sided chest tube following thoracotomy has continuous bubbling in collection chamber – a. take no action with collection device 51. Pre-op for left pneumonectomy for cancer of lungs – use incentive spirometer 52. Monitor strip for MI, no P wave, rate 162, R interval irregular, PR not measurable, QRS wide and distorted a. Ventricular tachycardia 53. 50 second episode of v. tach – a. administer IV antidysrhythmic drugs per protocol 54. MI develop symptomatic hypotension, hr 30, atropine is prescribed, effective when – a. increase in patient heart rate 55. Large MI has frequent PVC - monitor apical heart rate 56. Pt. complains of racing heart, BP 102/68, puts on cardiac monitor – a. obtain further info about possible cause for heart rate (STRIP) 57. Dizziness and SOB for several days a. 3rd degree av block (STRIP) 58. Nurse gets stuck by a needle – a. hep b vaccine and HBIG injection 59. Hepatitis from contaminated food, serologic testing result – a. anti-hepatitis virus immunoglobulin 60. Evaluation of patient at outpatient clinic, admin of hep B vaccine is effective when – a. anti Hep B are present in specimen 61. Positive for anti HCV – a. schedule patient for HCV genotype testing 62. Homeless patient, severe anorexia, jaundice, diagnosed with hepatitis – a. maintain adequate nutrition 63. Acute hep B asks if treatment is available – a. no meds are available to treat acute viral hepatitis, adequate nutrition and rest are the most important treatments (HB=NO MED)64. Combination therapy in HIV with hepatitis C patient – a. monitor lymphocyte count 65. When taking history, what should make you screen for hep C – a. One time use of IV drugs from years ago 66. Abrupt onset of jaundice, nausea, vomiting, hepatomegaly, abnormal liver function, what is the first question to ask – are you taking any OTC drugs? 67. Teaching pt. recovering from hep B, further teaching – a. when my jaundice is gone, my infection is cured, I’ve recovered 68. 32 yo very alcoholic, cirrhosis, teach them – abstinence from alcohol 69. Pt. with cirrhosis has 135 Na, 3.2 K, needs aldactone and Lasix, before notifying HCP – admin aldactone 70. When lactose is ordered for patient with advanced cirrhosis, pt complains diarrhea – a. lactose improves nervous system function 71. Acute pancreatitis, severe ab pain, N/V, expect – elevated amylase ☺ 72. Caring for patient with acute pancreatitis – assign highest priority to respiratory (airway) 73. Acute pancreatitis on NG tube, NPO, suction purpose – a. To reduction of pancreatic enzymes 74. Collaborative problem for acute pancreatitis electrolyte imbalance – a. muscle twitching and finger numbness 75. When obtaining history about acute pancreatitis – ask about alcohol use/consumption 76. During diuretic phase of ARF, fluid and electrolyte – a. hypovolemia 77. Before administering sodium polystyrene (kayexelate) – a. assess bowel sounds 78. Hypoglycemia awareness, what should nurse ask to identify potential hypoglycemia – a. did you notice any bloating feeling after eating? 79. Brain tumor receiving brain tumor after craniotomy was prescribe solumedrol – a. helps her prevent increased ICP 80. Cerebral edema with sodium of 115 low, decrease LOC, complains of headache – a. admin 5% hypertonic saline 81. Spinal cord tumor, which requires immediate intervention – a. new onset of weakness in both legs 82. Neck is fractured at C5 admitted to ICU, spinal shock assessment – a. flaccid paralysis and lack of sensation below the level of injury 83. Aspirin order on patient with possible stroke, don’t give it when – a. pt. develops a terrible headache 84. BP 120/60, ICP 24, CPP 56 (70-100) – a. this patient indicates impaired brain flow 85. Head injury, BP 92/50 ICP 18 – a. notify HCP about assessments86. Initial assessment hospitalized for stroke, BP 180/90, which order to question – Labetalol 87. Subarachnoid hemorrhage in ICU, call HCP if– a. patient’s BP is 90/50 (notify) 88. C5 injury highest priority – a. assessment of respiratory rate and depth 89. C8 spinal cord injury has weak cough effort, bibasilar crackles, decreased breath sounds – a. place hand on epigastric area and push upwards until patient coughs 90. T1 injury, tell family that – a. full function of patient’s arms will be retained 91. IV solumedrol effectiveness for spinal cord injury – a. assess for motor and sensory function of the legs 92. Paraplegia T10 has neurogenic reflex bladder teaching – a. teach pt. how to self-catheterize 93. T2 spinal cord, I feel awful, head is throbbing, sick to my stomach – I don’t get this Q a. take blood pressure 94. Long term goals with c6 spinal cord injury – a. push manual wheelchair on a flat smooth surface (it was blurry lol) 95. Sustained t1 becomes abusive to nurses and staff, demands transfer – a. ask patient’s input into the plan of care 96. C8 spinal cord, sex life – suggest sexual counseling 97. 25 yo patient following rehab for c8 injury, parent does all ADL – teach patient to foster independence 98. diabetic ketoacidosis intervention – a. infuse 1 Liter of normal saline / hour 99. Hyperglycemic hyperosmolar nonketotic syndrome (HHNC) unresponsive in ER – a. insert large bore IV catheter 100.Bacterial meningitis, report if – BP is 86/42 ...CONTD [Show Less]
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ATI RN ADULT MEDICAL SURGICAL 2021/22 [NEW & VERIFIED]
1. A nurse is assessing a client who has a diagnosis on colon cancer which of the following should the nurse expect? a) Statorrhea b) Elevated hemoglobi... [Show More] n c) Hematochezia d) Weight gain 2. A nurse is assessing a client admitted with peripheral vascular disease,. Which of the following findings indicates a venous vascular disorder? a) An ulcer at the tip of a toe b) Hair loss distal to the clients calves c) Leg pain at rest d) Edema of the ankle 3. A nurse is assessing a client who has pericarditis. In which of the following areas of the client’s chest should the nurse place the stethoscope to best hear a pericardial friction rub? (select HOT spot)Answer: D 4. A nurse is caring for a client who has a chest tube. The client asks why the fluid in the water -seal chamber rises and falls. Which of the following statements should the nurse make? a) “ this means your lung is fully expanded “ b) “ this indicates a possible leak” c) “ suction pressure that is too high causes this” d) “ Your breathing pattern causes this” 5. A community health nurse is reviewing home care instructions with an older adult client who has a new diagnosis of heart failure. Which of the following is the priority topic for the nurse to review with the client? a) Daily sodium restriction b) Daily exercise routine c) Changes in weight d) Fluid intake record6. A nurse is teaching a client about the use of transcutaneous electrical nerve stimulation (TENS) unit. Which of the following statements should the nurse include? a) “Apply lotion to the site prior to attaching the electrodes” b) “ this device requires access to a 220 volt outlet” c) ‘ this device delivers heat via electrodes that are attached to the effected area” d) “adjust the dial until you feel a ‘pins and needles’ sensation” 7. A nurse is providing teaching to a client who is postoperative following a total hip arthroplasty. Which of the following statements should the nurse make? a) “ use raised toilet seat to maintain your hips above the knees” b) “ twist at the waist when standing from a seated position” c) “move your stronger leg first when using a walker” d) “ apply a heating pad to the operative hip to decrease pain” 8. A nurse finds a client in bed, unresponsive and breathing. Which of the following action should the nurse take first? a) Establish IV access b) Apply blood pressure cuff c) Palpate for the client’s carotid pulse d) Initiate cardiac monitoring for the client 9. A nurse is caring who is experiencing a hypertensive crisis. Which of the following actions should the nurse take? a) Initiate IV dopamine infusion b) Perform neurological assessments c) Place the client supine d) Begin an IV bolus of lacted ringer’s 10. A nurse is providing discharge teaching about blood sugar monitoring for a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should instruct the client to obtain which of the following supplies? a) Sterile lancets b) Compression stockings c) Hand mirrord) Toenail clippers 11. A nurse is completing discharge teaching who has a peripherally inserted central catheter ( PICC) line in the left arm. Which of the following instructions should the nurse include in the teaching? a) Do not elevate the arm above the level of the heart b) Change the catheter dressing daily c) Use 10- mL syringe to flush line d) Clean the insertion site using 20- mL of hydrogen peroxide 12. A nurse is preparing naloxone 10 mcg/kg via IV bolus to a client who weights 220 lbs. the amount available is 0.4 mg/mL . how many mL should the nurse administer? ( round to the nearest tenth) 13. A nurse is caring for a client who has a sealed radiation implant. Which of the following actions should the nurse take? a) Remove soiled linens from the room after each change b) Give the dosimeter badge to the oncoming nurse at the end of the shift c) Apply a second pair of gloves before touching the client’s implant if it dislodges d) Limit family member visits to 30 min per day 14. A nurse is providing teaching to a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication? a) Generalized abdominal pain b) Cloudy effluent c) Increased heart rate d) Fever 15. 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) Pantoprazole b) Acetaminophen c) Furosemided) Diphenhydramine 16. A nurse is planning care for a client who has upper gastrointestinal bleeding due to a peptic ulcer. Which of the following actions should the nurse plan to take? a) Provide ketorolac for abdominal pain b) Administer nitroprusside IV based on the client’s weight c) Insert a large bore nasogastric tube d) Ensure that the client has a 22- gauge iv line in place 17. A nurse is caring for a client who has bladder cancer and a WBC count of 900/mm3 . which of the following actions should the nurse take? a) Instruct client to avoid eating raw fruit b) Move the client to a negative pressure room c) Use contact isolation while providing care d) Apply pressure to venipuncture sites for 10 min 18. A nurse is caring for a patient who has hypotension, cool and clammy skin, tachycardia and tachypnea. Which of the following positions should the nurse place the client? a) Reverse Trendelenburg b) Feet elevated c) Side lying d) High – fowler’s 19. A nurse is caring for a client who weights 190 lb and is receiving Total parenteral Nutrition. if the RDA Protein is 0.8g/kg Of body weight, how many grams of protein should the client receive daily ( Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero) Answer: 69 grams 20.A nurse is planning care for a client who has a central venous access device for intermittent infusions. Which of the following actions should the nurse include in the plan of care? a)Flush a catheter using a 10 mL syringe b) Use clean technique when changing the dressing c) Cleanse the site with Provo dine iodine d) Change the dressing every 24 hours21. A nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the following findings should the nurse report to the provider as a contradiction to receiving heparin? a) Thalassemia b) Rheumatoid arthritis c) COPD d) Thrombocytopenia 22. A nurse is caring for an older adult client who has dementia. Which of the following question should the nurse ask to assess the client's abstract thinking? a) What is meant by saying “don't beat around the bush?” b) What do you understand about your condition c) Can you count backwards from 100 in intervals of 7? d) Can you state where you were born? 23. A Nurse is completing an assessment of an older adult 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? a) Apply an occlusive dressing b) turn and reposition the client every 4 hours c) support bony prominences with pillows d) massage Tourette in areas three times daily 24. A nurse is reviewing a cardiac Rhythm strip of a client who has atrial flutter. Which of the following findings should the nurse expect? a) Progressively longer PR durations b) undetectable p waves c) absent PR intervals with ventricular rate of 40 to 60 / minutes d) Sawtooth pattern with atrial rate of 252 400 / minutes 25. A nurse is caring for a client who is scheduled for an abdominal paracentesis. The nurse should plan to take which of the following actions? a) Administer a stool softener following the procedure b) ask the client to empty his bladder prior to the procedure c) instruct the client to take deep breaths and hold them during the procedure d) assist the client into the left lateral position during the procedure 26. A nurse is assessing a client following the insertion of a central venous catheter. Which of the following findings indicates a pneumothorax?a) diminished breath sounds b) itching over the incision c) distended neck veins d) irregular heart rate 27. A nurse is providing teaching to a client who is receiving opioids for pain management. Which of the following information should the nurse include in the teaching? a) Monitor urinary output for retention b) avoid taking anti emetics with the medication c) restrict fluid intake If you experience constipation d) itching Indicates you are having an allergic reaction to the medication 28. A nurse is providing discharge teaching for a client who has asthma and a new prescription for a metered dose inhaler. Which of the following client statements indicates an understanding of the teaching? a) I should clean the cap of the inhaler once per week b) I should shake the inhaler before I use it c) I Should wait 15 seconds between puffs d) I should inhale the medication quickly 29. A nurse is providing preoperative teaching for a client who is having left-sided cardiac catheterization. Which of the following information should the nurse include in the teaching? a) You should plan to remain in bed for 18 hours after the procedure b) you will have blood pressure measurement every 5 minutes for the first two hours after the procedure c) You will receive a general anesthetic during the procedure d) you should expect warm sensation after the injection of the contrast dye during the procedure 30. A nurse is caring for a client who has anemia. Which of the following assessment findings should the nurse anticipate with the client's condition? a) Bradycardia b) Headache c) heat intolerance d) flushed skin color 31. A nurse is teaching a client who has a new prescription for Warfarin about foods that affect the INR. The nurse should include in the teaching that which of the following Foods interact with this medication? a) Kale b) beef stewc) Yogurt d) orange juice 32. A nurse is monitoring an older adult client who has an extrapolation of chronic lymphocytic leukemia. The nurse notes patikayy on the client's skin which of the following actions should the nurse take? a) Determine the client's blood type b) avoid administering IV pain medication c) Implement airborne precautions d) Institute bleeding precautions 33. A nurse is providing discharge teaching for a client who is receiving treatment for genital herpes. Which of the following statements by the client indicates effectiveness of the teaching? a) I should expect to take my medication for three weeks b) I should apply antibiotic ointment to the lesions c) I should expect my lesions to resolve in 6 weeks d) I should use natural skin condoms during sexual intercourse 34. A nurse in an emergency department is preparing a client for emergency surgery. The client's blood alcohol level is 180 mg / DL which of the following action is the nurses priority? a) Insert an NG Tube b) obtain consent for surgery c) apply anti embolic stockings d) insert an indwelling urinary catheter 35. A nurse suspects that a client who has diabetes mellitus is experiencing hypoglycemia. Which of the following assessment findings supports this suspicion? a) Cool, clammy skin b) kussmaul respirations c) acetone breath d) increased urine output 36. A nurse is caring for a client who is receiving radiation. The client reports nausea since the therapy was initiated. Which of the following considerations should the nurse include when finding the clients meals? a) Offer hot beverages with meals b) offer a snack prior to radiation therapy c) offer highly seasoned Foods d) offer frequent High carbohydrate meals37. A charge nurse receives a call from the house supervisor requesting room assignments for four new clients. Based on the information diagnosis which of the following clients requires a private room? a) A client service port reports having fever, night sweats, and call for 2 days b) an older adult client who was admitted with aspiration pneumonia c) a client who has diabetes mellitus and is presenting with acute ketoacidosis d) a client who has a compound fracture of the right femur 38. A nurse in an emergency department is assessing a client who has diabetic ketoacidosis. Which of the following findings should the nurse expect? (select all the apply) a) Tremors b) reports of nausea and vomiting c) Serum glucose 380 mg / DL d) serum pH 7.6 e) fruity smelling breath 39. A nurse is planning a staff education session about hepatitis A. Which of the following information should the nurse include? a) Immunization for Hepatitis A is recommended prior to travel to high-risk areas b) the incubation. Of hepatitis A is 5 to 10 days c) hepatitis A is transmitted is Through Blood to blood exposure d) clients who have Hepatitis A require a broad-spectrum antibiotic 40. A nurse is caring for a client who has advanced liver disease. Which of the following laboratory results should the nurse monitor when assessing this client? a) Phosphate level b) glucose level c) serum troponin d) Serum ammonia 41. A nurse is planning care for a client who has status epilepticus. Which of the following interventions is the nurses priority to include? a) Administer phenytoin IV bolus to the client b) provide the client oxygen at 6 L / min using a nasal cannula c) turn the client to the lateral position during seizure activity d) administer diazepam intravenously to the client 42. A nurse is caring for a client who had a total hip arthroplasty. Which of the following actions should the nurse take to prevent hip dislocation? a) Elevate the knees higher than the hips when sitting b) remove the wedge device when turningc) encourage the client to lean forward when attempting to stand d) place two bed pillows between the legs when in bed 43. A nurse is caring for a client who is receiving Total parenteral Nutrition (TPN) The crane infusion is almost complete and the new solution is not available which of the following actions should the nurse take? a) Infuse dextrose 10% in water b) decrease that tpn infusion rate c) disconnect and flush the IV access line d) administer lactated ringers through the peripheral IV site 44. A nurse is caring for a client who is 6 hours postoperative following application of an external fixator for a tibial fracture. Which of the following actions should the nurse take? a) Adjust the clamps on the fixator frame b) maintain the affected extremity in a dependent position c) palpate the dorsalis pedis pulse d) rap sterile gauze on the sharp point of the pins 45. A nurse is caring for a client in the emergency department who experienced a full thickness burn injury to the lower torso 1 hour ago. Which of the following findings should the nurse expect? a) Hypotension b) Bradycardia c) decrease respiratory rate d) urinary diuresis 46. A nurse is planning care for an older adult client who has Meniere's disease. Which of the following interventions should the nurse include in the plan? a) Perform range of motion exercises to the client's neck every 4 hours b) limited clients fluid intake to 1500 ml / day c) administer aspirin if the client reports a headache d) encourage the client to change position slowly47. Was not able to take photo of question.. But i remember choosing the second option... 48. A nurse is caring for a client admitted with a skull fracture. which of the following assessment findings should be of greatest concern to the nurse? a) Pulse pressure changes from 30 to 20 mmhg b) bilateral pupil diameter changes from 4 to 2 mm c) WBC count changes from 9,000 to 16,000 / mm 3 d) Glasgow Coma Scale score changes from 14 to 9 49. A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take when performing a close intermittent irrigation?a) Use a 3ml syringe to perform the catheter irrigation b) Clamp the catheter above the specimen port c) place the client in Trendelenburg position d) inject the irrigation solution slowly into the catheter 50. A nurse is completing discharge teaching with a client who has a new diagnosis of AIDS. Which of the following statements by the client indicates an understanding of the teaching? a) I will need to take my clothes to the dry cleaners to sterilize them b) I will wipe up areas soiled with body fluids with alcohol and immediately disposed of the trash (should be cleaned with bleach not alcohol ) c) I will be sure to wear gloves and wash my hands when I change my cat's litter box d) I will increase the amount of fresh fruits and vegetables I consume ... CONTD [Show Less]
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ATI MEDSURG PROCTORED EXAM QUESTIONS WITH 100% CORRECT ANSWERS 2021/22
1. A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? a. Bradycardia- more tachycard... [Show More] ia cuz of a failing ventricle , SNS is activated to compensate . b. Flushed skin- duskly it wIll look like c. Frothy sputum-Left sided- can be blood tinged d. Jugular vein distention→ Right Rationale: ATI MS: pg. 198 ch 32 pdf Left side: dyspnea, orthopnea, fatigue, pulmonary congestion, frothy sputum, organ failure such as oliguria. Right Side: Jugular vein distention, ascending dependent edema, abdominal distention, polyuria ar rest, liver enlargement, 2. A nurse is assessing a client who is experiencing renal colic from a calculus in left renal pelvis. Identify the area where the nurse should expect the client to have referred pain. ( Find “hot spots” in the artwork) Pain travels downward to the inguinal area and lower back Renal colic occurs in the kidney area. Referred pain is somewhere that happens in another place other than where the pain should be felt. 2. A nurse is caring for a client who is receiving peritoneal dialysis and notes a decrease in the dialysate flow rate. Which of the following actions should the nurse take? (Select all the apply?). Check answer i read pg 644-647 med surg it’s not so specific p. 370 ch 57 pdf a. monitor the access site for drainage.- to check for sxs of infection. b. Strip the catheter tubing c. Measure the amount of the dialysate outflow d. Raise the client to high fowlers position- they must lie supine e. Position the client to her other side. 3. A nurse is planning to insert an indwelling catheter for a female client. Which of the following actions should the nurse plan to take? Ati video tutorials foley a. Collect urine specimen from the drainage bag 1 hr after insertion b. Raise the head of the bed to 45 degrees prior to insertion c. Secure the catheter to the client's inner thigh d. Attach the bag to the rail of the bed. –under non movable area 6. A nurse is providing teaching for a client who has age-related macular degeneration which of the following information should the nurse include in the teaching a. A possible cause of this problem is long-term lack of dietary protein b. You probably have a Detachment of your retina -vision is like having curtains over eyes c. You probably have noticed a decline in your central vision d. The doctor can perform surgery to correct the start paying the folds in your retina Rationale: ATI MS: PG. 63 Macular degeneration, often called age-related macular degeneration (AMD), is the central loss of vision that affects the macula of the eye. NO cure , happens alot in old people. Sxs: distorted vision, blurred vision, caused by smoking, female, HTN, diet lacking carotene.7. A nurse is assessing a client who has cirrhosis. Which of the following findings is the priority for the nurse to report? P . 357 ch 55 pdf Med surg a. Platelets 70,000/mm3- risk of bleed normal range is 150,000 - 300,00- ABCS is compromised automatically . b. Distended abdomen- expected c. Alkaline phosphatase 125 units/L -norm normal is 30 -120 D. Clay colored stools- bile not on your shit 8. A nurse is preparing to discontinue long-term total parenteral nutrition (TPN) therapy for a client for a client. The nurse should plan to discontinue the TPN gradually to reduce the risk of which of the following adverse effects? Old med surge docs we used a. Hyperglycemia b. Diarrhea c. Constipation d. Hypoglycemia (Repeat) Since your body is producing enough insulin to take on higher loads, you must taper it down to avoid hypoglycemia with lower concentrations of TPN Abruptly discontinuing TPN will cause rebound hypoglycemia 9. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse plan to take? P . 250 chapter 40 pdf p . 678 lewis a. Administer the unit of packed RBC’s over 1 hr- 2- 4 hr its must be given for 2 -4 hours. older adults b. Obtain the client’s first set of vital signs 1 hr after initiating the transfusion- you get vital signs at the initial first 15 to 30 minutes of the transfusion. c. Initiate venous access with a 21-gauge needle - no more than 19, for a regular adult it is 18 or 20 . d. Use Y tubing with 0.9% sodium chloride when administering the transfusion. Pg 249 10. TOXIC SHOCK SYNDROME- same 11. A nurse is providing discharge teaching to an older adult client who had an exacerbation of COPD. The client is to start fluticasone by metered-dose inhaler. WHich of the following instructions should the nurse include? ( C) p . 132 ch 22 a. Use fluticasone as needed for shortness of breath.- fluticasone used to treat inflammation. b. Limit fluid intake to 1 L per day. - drink plenty to avoid dehydration. 2-3 liters. c. Obtain a yearly influenza immunization. - reduce risk of infection. d. Assist use of pursed-lip breathing.- this is also one of the interventions the nurse does but the question ask about fluticasone. It is a steroid, and we all know steroids decresaes inflammation but also depress our immunue system. So getting a flu shot is priority. 12. A nurse is providing discharge teaching to an older adult client following a left total hip arthroplasty. Which of the following instructions should the nurse include in the teaching? a. “You can cross your legs at the ankles when sitting down.” -avoid flexion contraction b. “Clean the incision daily with hydrogen peroxide.”- soap and water c. “Install a raised toilet seat in your bathroom.” Pg 437 also use straight chairs with arms, abduction pillow between the legs, avoid low chairs, and flexion of hip greater than 90 degrees. NO crossing legs , no turing on operative side. d. “You should use an incentive spirometer every 8 hrs.”- once every hour at least 13. Missing 14. A nurse is caring for a client who is postoperative following a femur fracture. Which of the following findings should the nurse report to the provider immediately? a. The client reports shortness of breath - embolism ABCS p . 457 chapter 71 b. The client has a temperature of 38.1 C (100.5F) c. The clients incision is red and warm d. The client reports incision pain15. A nurse is planning care for a client who Clostridium difficile gastroenteritis. Which of the following is an appropriate nursing action? P . 290 ch 46 pdf a. Place the client in a protective environment b. Obtain a stool specimen with gloves→ CONTACT ISO c. Clean surfaces with chlorhexidine-bleach D. Wash hands with alcohol-based hand rub. 16. A nurse is setting up a sterile field before performing a dressing change on client who is postoperative. Which of the following actions should the nurse plan to take to maintain the sterile field? (select all the apply) a. Grasp 2.5 cm (1 in ) of the outer edge to open the surgical wrap- 1 inch form broder is always non sterile so its ok to touch it . b. Select a work surface at the nurses waist level- body mchiancis . c. Apply sterile gloves before opening the pack- sterile package must be opened first before donning sterile gloves d. Open the first flap of the sterile package toward the nurse's body- must be AWAY first , then sides , then TOWARDS the nurse . e. Place a surgical pack with a sterile drape on the work surface. 17. A nurse is caring for a client who has acute appendicitis. Which of the findings is the priority to the provider? Ch 23 p . 143 PEDIATRICS pdf also p 944 lewis a. Nausea- has not burst b. Flank pain - normal c. Fever - has not burst d. Rigid abdomen - muscles contract because it exploded- can lead to rupture and infection also HR ELEVATED, shallow and rapid respirations, pulse is weak. . 18. A nurse is caring for a client who is receiving radiation. The client reports nauseas since the therapy was initiated. Which of the following considerations should the nurse include when planning the clients meals? P . 583 ch 91 also ch 16 p 269 of the lewis book a. Offer frequent, high-carbohydrate meals- several small meals a day is preffered. b. Offer highly seasoned foods- you want COLD , dry , foods. Cooking stimulates odors that lead to nausea. c. Offer a snack prior to radiation therapy- several small meals a day is recommended. d. Offer hot beverages with meals- hot foods can stimulate nausea. Beverage with meals leads to nausea. 19. A nurse is caring for a client who is receiving mechanical ventilation. Which of the following interventions should the nurse implement? (D) page 208-209 not sure which answer Empty water from the ventilator tubing daily. ( -INFECTION CONTROL: water that collects in the ventilator tubing can create a breeding ground for bacteria which may lead to VAP. Suction the client’s airway every 4 hr.(Suction every 2 hr and as needed. p.157) Maintain the client in supine position. (should reposition pt to help with secretions) Perform oral care every 2 hr.( you do oral care but not every 2hrs ) 20. A nurse in an emergency department is assessing a client who has cirrhosis of the liver. Which of the following is a priority finding? ( C) a. Palmar erythema b. Spider angiomas c. Mental confusion (RM 10 Ch.55 p.359 pdf - too much bilirubin in the blood went to the brain and now caused mental encephalopathy) d. Yellow Sclera 21. A nurse is preparing to administer bumetanide to a client who has heart failure. Which of the following assessment findings should indicate effectiveness of the medication a. Bowel sounds present in 4 quadrants on auscultation b. Alert and oriented to time place and personc. Lung sounds clear - it is Bumex d. Apical pulse 80 Rationale: MS RM 10 Ch.32 p.198-9 23. A nurse is caring for a client who has hypertension and has a new prescription for lisinopril. The nurse should consult with the provider about which of the following medication in the client's medication administration record? a. Potassium chloride ** found on medscape b. evothyroxine c. Acetaminophen d. Metformin Rationale: Pharm RM 7.0 Ch.20 p.151; Hyperkalemia is a complication for Lisinopril; avoid any salt substitutes containing K+. 24. A nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan or care? a. Avoid use of anticoagulants - use it b. Place pillow under client knees - stasis danger c. Discourage leg exercises while in bed - you need it d. Apply compression stocking in lower extremities Rationale: It’s common post-op, also, resume regular activity after 4-6 wks. 25. What interferes with warfarin therapy a. Potatoes (Potassium) Oranges (Vit C) b. Bananas (Potassium) c. Cauliflower - Huge Vitamin K remember veggies Rationale: Avoid any interaction with Vitamin K when on anticoagulant therapy, and dark, leafy veggies (or just any veggies) are THE source for it. 26. A nurse is administering furosemide 80 to a client with pulmonary edema. Which of the following assessment findings indicates the nurse that the medication is effective? P , 144 ch 19 pharm pdf a. Elevation in BP b. Adventitious breath sounds c. Weight loss of 1.8 kg (4lb) in the past 24 hr d. Respiratory rate of 24/min 27. A nurse is caring for a client who has Cushing’s disease. Which of the following findings should the nurse expect? Ch 80 page 518 a. Weight loss b. Hyponatremia- increased c. Hyperglycemia d. Hypercalcemia- DECREASED ERRYTHANG is UP except K+/Ca+, both HYPO 28. A nurse is monitoring a client who has receiving 2 units packed RBCs. Which of the following manifestations indicates a hemolytic transfusion reaction? (MS RM 10.0 Ch.40 p.250: chills, fever, low-back pain, tachycardia, flushing, hypotension, chest tightening or pain, tachypnea, nausea, anxiety, hemoglobinuria, and an impending sense of doom) a. Back pain b. Bradycardia- should be tachycardia c. Hypertension- hypotension it will cause. d. Chills29. A PACU nurse is monitoring the drainage from a client’s NG tube following abdominal surgery. Which of the following findings in the first postoperative hour should the nurse report to the provider? a. 75 mL of greenish yellow drainage (Purulent) b. 100 mL of red drainage (Sanguineous/fresh bleeding) c. 200 mL of brown drainage (Purulent) d. 150 mL of serosanguineous drainage 30. A nurse is performing an admission assessment on a client who has severe chronic kidney disease. Which of the following findings should the nurse expect? MS RM 10.0 Ch.59 p.382 pdf a. Lethargy b. Potassium 4.0 mEq/L c. Hypotension- HTN due to fluid overload d. Serum creatinine 0.9 mg/dL- should be increased . Rationale: Expected findings include nausea, fatigue, lethargy, involuntary movement of legs, depression, and intractable hiccups. In most cases of chronic CKD, findings are r/t fluid overload, including both HTN and orthostatic hypotension. 31. Missing 32. A nurse is teaching a client who has hypothyroidism. Which of the following information should the nurse include in the teaching? (select all the apply) pg. 886 med srg a. You will take medication for this condition for several months b. You will need to eat a high-fiber diet to prevent complications of this condition c. You might notice that you perspire more with this condition d. We will perform laboratory tests to monitor the effect of your medication e. This condition can cause you to gain weight. 33. A nurse is caring for a client who is receiving mechanical ventilation when the low pressure alarm sounds on the ventilator. Which of the following actions should the nurse take? P 113 ms ati pdf a. Empty water from the client’s ventilator tubing b. Evaluate the client for a cuff leak - check this first for cause of low pressure c. Suction the client’s airway d. Increase the client’s ventilator flow rate. 34. A nurse is reviewing laboratory results for four clients who are scheduled for surgery. Which of the following laboratory values should the nurse report to the surgeon?...CONTD [Show Less]
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ATI MED SURG Respiratory 2021/22 (DOWNLOAD TO SCORE A)
1- A charge nurse receives notification of the admission of a client who is coughing frequently and whose sputum is pink, frothy, and copious. The client ... [Show More] has history of night sweats, anorexia, and weight loss. Which of the following actions should the nurse take? (SATA) -Assign the client to a private room with negative-pressure airflow -Wear an N95 respirator when entering the client’s room. 2- A nurse is assisting a provider with a comprehensive physical examination of a client. When the provider uses transillumination, the nurse should explain to the client that this technique help evaluate which of the following structures? -Maxillary sinuses 3- A nurse is caring for a client who smokes cigarettes and has a new diagnosis of emphysema. How should the nurse assist the client with smoking cessation? -Discuss ways the client can reduce the number of cigarettes smoked per day. 4- A nurse is planning care for a client who has chronic obstructive pulmonary disease (COPD) and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan? -Eat high-calorie food first. Rational: client who has COPD experience early satiety. Client should eat calorie-dense food first. [Show Less]
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Capstone Med Surg Assessment 2021/22 (ALL ANSWERS CORRECT)
Capstone Med Surg Assessment 1. A nurse is teaching a client about using a continuous positive airway pressure (CPAP) device to treat obstructive sleep a... [Show More] pnea. Which of the following information should the nurse include in the teaching? It delivers a present amount of airway pressure throughout the breathing cycle 2. A nurse is providing discharge teaching to a client following a heart transplant. Which of the following information should the nurse include in the teaching? Shortness of breath might be an indication of transplant rejection 3. A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and is receiving 3 % sodium chloride via continuous IV. Which of the following laboratory finding should the nurse identify as an indication that the SIADH is resolving? Urine specific gravity 1.020 4. A nurse is teaching a client about fecal occult blood testing (FOBT) for the screening of colorectal cancer. Which of the following statements should the nurse include in the teaching? You should avoid taking corticosteroids prior to testing 5. A nurse is preparing a client for a colonoscopy. Which of the following medications should the nurse anticipate the provider to prescribe as an anesthetic for the procedure? Propofol 6. A nurse is planning care for a client who has acute pancreatitis. Which of the following interventions should the nurse include in the clients plan? Select all that apply. Monitor blood glucose levels Maintain NPO status until pain-free Manage acute pain7. A nurse is teaching a client who has hypertension about dietary modifications to help control blood pressure. Which of the following food choices should the nurse recommend as the client to include in their diet? 3 oz of chicken breast 8. A nurse is reviewing the medical record of a client who has unstable angina. Which of the findings should the nurse report to the provider? Breath Sounds 9. A nurse is providing discharge instructions to a client who has GERD. Which of the following statements by the client demonstrates an understanding of the teaching? I will limit activities that require bending at the waist. 10. A nurse at a provide office is interviewing a client who has multiple sclerosis and has been taking dantrolone for several months. Which of the following client statements should the nurse identify as an indication that the medication is effective? I don’t have muscle spasms as frequently 11.A nurse is assessing a client who reports a possible exposure to HIV. Which of the following finding should the nurse identify as an early manifestation of HIV infection? Fatigue 12.A nurse is teaching a client who has type 1 diabetes mellitus about hypoglycemia .which of the following statements by the client indicates an understanding of the teaching? I can drink 4 ounces of soda if my blood sugar is low 13.A nurse is providing discharge teaching to a client who has heart failure and a prescription for furosemide 20 mg PO two times daily. Which of the following instructions should the nurse include in the teaching? Increase intake of high-potassium foods14.A nurse is caring for a client who has burn injuries covering their upper body and is concerned about their altered appearance .Which of the following statements should the nurse make? It could be helpful for you to attend a support group for people who have burn injuries. 15.A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine .Which of the following interventions should the nurse include in the plan? Monitor the client skin under the halo vest. 16.A nurse is caring for a client who has a traumatic brain injury. Which of the following finding should indicate to the nurse the need for immediate intervention? Respiratory rate 30/min 17.A nurse is assessing a client who has meningitis. The nurse should identify which of the following finding as a positive Kerning s sign? After stroking the lateral area of the foot, the client’s toes contract and draw together. After hip flexion, the client is unable to extend their leg completely without pain 18.A nurse is teaching a group of assistive personnel (AP) about caring for client who have Alzheimer’s disease. Which of the following information should the nurse include in the teaching? Provide supervision to prevent a client from becoming injured or lost. 19.A home health nurse is providing teaching to the family of a client who has a seizure disorder. Which of the following interventions should the nurse include in the teaching? Keep a padded tongue blade near the bedside. Place a pillow under the client's head while in bed during a seizure. Administer diazepam orally at the onset of seizures.Position the client on their side during a seizure. 20.A nurse is contributing to the plan of care for a client who has pyelonephritis. Which of the following interventions should the nurse include? Encourage the client to consume caffeinated beverages Avoid the use of acetaminophen for discomfort Monitor the clients the urine for color changes Begin antibiotic therapy after culture and sensitivity results are obtained 21. Nurse is assessing a client who has a herniated lumbar disc. Which of the following findings should the nurse expect? The client reports relief from pain when lying in the prone position. The client reports that her low-back pain radiates upward toward one scapula. The client reports tingling and a burning sensation in one foot. The client reports decreased pain when the affected leg is raised and straightened 22.A nurse is caring for a client who has acute gastritis and is NPO. The client has a new prescription to resume oral intake. Which of the following items should the nurse offered the client? Lemonade Tomato soup Gelatin Black coffee 23.A triage nurse nds a school-age child lying in the road following a school bus crash with multiple casualties. The child has a respiratory rate of 8/min, is unresponsive to verbal commands, and groans to painful stimuli. The nurse should assign the client which of the following triage tags?Red Yellow Green Black 24.A nurse is teaching a client who has a new diagnosis of polycystic kidney disease. Which of the following statements should the nurse include in the teaching? "Take aspirin as needed to reduce your pain." "Reduce your dietary beer intake." "Apply dry heat to your abdomen when needed." "Check your weight once per week." 25. A nurse is assessing a client who has right lower lobe pneumonia. Which of the following findings should the nurse expect? Dull percussion sounds Increased anterior posterior chest diameter Distended neck veins Pitting edema 26.A nurse is providing teaching to the caregivers of a client who has Alzheimer's disease. Which of the following instructions should the nurse give? (Select all that apply.) Install safety locks and alarm systems. Place nightlights throughout the home. Replace carpeted flooring with tile. Establish a predictable daily routine for the client. Remind the client of scheduled activities 1 day in advance. 27.A nurse is caring for a client who is hyperventilating and has the following ABG results: pH 7.50, PaCO 29 mm Hg, and HCO 25 mEq/L. The nurseshould recognize that the client has which of the following acid-base imbalances? 2 3 – Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis 28.A nurse is providing discharge teaching for a client who has COPD about nutrition. Which of the following instructions should the nurse include? Eat three large meals daily. Consume high-calorie foods. Limit caffeinated drinks to two per day. Drink fluids during mealtime 29.A nurse is caring for a client who has a right-sided pneumothorax. Following chest tube insertion, which of the following findings indicates that the chest drainage system is functioning correctly? Gentle bubbling in the suction chamber Crepitus around the insertion site Constant bubbling in the water seal chamber Absence of breath sounds on the right side 30.A nurse is caring for client who has a new diagnosis of tuberculosis. Which of the following precautions should the nurse initiate to present transmission of the disease? Contact precautions Airborne precautions Droplet precautions Protective environment31.A nurse is planning care for a client who has Ménière's disease and is experiencing episodes of vertigo. Which of the following interventions should the nurse include in the plan? Maintain strict bed rest. Restrict uid intake to the morning hours. Administer aspirin. Provide a low-sodium diet. 32.A nurse reviewing laboratory reports for client who is taking NSAISs for rheumatoid arthritis. Which of the following results should the nurse recognize as a possible adverse effect of NSAID therapy? Increased erythrocyte sedimentation rate Elevated creatinine clearance Increased serum potassium Positive fecal occult blood test 33.A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings indicates the client might be experiencing a hemolytic transfusion reaction. Hypertension Report of urticarial Distended neck veins Report of chest pain 34.A nurse is caring for a client who had surgery 2 days ago and reports incisional pain. Which of the following actions should the nurse take first? Determine the time the last dose of pain medication was administered. Reposition the client to assist with reduction of pain. Ask the client to describe the pain and rate it on a scale of 0 to 10. Para mi Check the client's medical record for type of PRN pain medication.35.A nurse is teaching strategies to prevent carpal tunnel syndrome to a group of oce workers. Which of the following instructions should the nurse include? (Select all that apply.) "Raise your chair height so that you lean over to type." "Use a wrist rest when working at a computer station." "Stretch your ngers and wrists periodically while working." "Position your keyboard at shoulder height." "Take breaks from the repetitive activity." 36.A nurse is assessing a client who has a tension pneumothorax following blunt chest trauma. Which of the following findings should the nurse expect? Tracheal deviation to the unaffected side Pleural friction rub Frothy, pink-tinged sputum Increased breath sounds on the affected side 37.A nurse is caring for an adult client who asks about vaccinations against communicable diseases. The nurse should inform the client that which of the following vaccines are available? (Select all that apply) Hepatitis A vaccine Hepatitis B vaccine Pneumococcal vaccine Hepatitis C vaccine Helicobacter pylori vaccine 38.A nurse is teaching a client who has angina pectoris about nitroglycerin sublingual tablets. Which of the following statements should indicate to the nurse that the client understands the teaching? "I will keep the tablets in the original container." "I should keep the container in my shirt or pants pocket." "I should begin to feel relief within 20 minutes of taking the medication." "I will drive myself to the emergency room if three nitroglycerin tablets do not relieve my pain."39.A nurse is preparing to administer epoetin to a client who has anemia due to chemotherapy. Which of the following actions should the nurse plan to take? Review the client's Hgb level prior to administration. Use the Z-tract method when administering the medication. Shake the vial for 30 seconds prior to withdrawing the medication. Ensure the client is not taking iron supplements while on this medication. 40.A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following findings should the nurse report to the provider immediately? Decreasing leg strength Decreasing voice volume Decreased deep tendon reflexes Decreased sensation in the arm 41. A nurse is assessing a client who has Addison's disease. Which of the following manifestations should indicate to the nurse that the client is experiencing an Addisonian crisis? Hypothermia Increased deep tendon reflexes Hypotension Erythema of the neck and chest 42.A nurse is caring for a client who has a cerebellar tumor. Which of the following actions is the nurse's priority? Provide assistance with ambulation. Facilitate retention of facts by repeating instructions. Place the client in a darkened room. Speak slowly and clearly. 43.A nurse is providing teaching to a newly licensed nurse about caring for a client who is receiving a ealed radioactive implant. Which of the following information should the nurse include in the teaching? Place soiled linens in a lead container. • Allow children who are over 10 years old to visit.Limit visitors to 1 hr per day. Wear a lead apron during care 44.A nurse is assessing a client who is postoperative following a kidney transplant. Which of the following findings indicates the client is experiencing a transplant rejection? Polyuria • Hypothermia Hypertension Hypovolemia 45.A nurse is providing teaching to a client who is scheduled for a bone marrow biopsy taken from the iliac crest. Which of the following information should the nurse include? "Avoid taking warm baths following the procedure." • "You will lie on your back during the procedure." "You will receive general anesthesia for the procedure." "Take acetaminophen as prescribed for pain relief after the procedure." 46.A nurse is providing discharge instructions to a client who has a peptic ulcer. Which of the following dietary modications should the nurse include? Provide a snack at bedtime. • Choose decaeinated coee. Restrict intake of fried foods. Avoid drinking liquids with meals 47.A nurse is assessing a client following a hypophysectomy. Which of the following findings indicates the client might be developing diabetes insipidus? Urine ketones Hyperglycemia • Halo or ring-shaped dressing drainage Low urine specic gravity48.A nurse is assessing a client who has a history of migraine headaches with aura and reports feeling "a migraine coming on." The nurse should expect the client to report which of the following manifestations? Visual disturbances • Photophobia Nasal congestion Phonophobia 49.A nurse is reviewing laboratory values for a client who has Cushing's disease. Which of the following values should the nurse expect? Blood glucose 65 mg/dL • Serum calcium 12.2 mg/dL Potassium 5 mEq/L Sodium 150 mEq/L 50.A nurse is assessing a client who has had a left-hemisphere stroke. Which of the following findings should the nurse expect? Expressive aphasia • Poor impulse control Left hemiparesis Disorientation to place 51.A nurse is assessing a client who has a mild traumatic brain injury. The nurse should report which of the following findings as a complication of this injury? (Select all that apply.) Bradycardia Vomiting Drainage from the ear para mi Unequal pupils Pruritus 52.A nurse is providing discharge teaching to a client who has multiple sclerosis. Which of the following instructions should the nurse include in the teaching?"It is important to engage in a strenuous aerobic exercise program to build strength and endurance." "It is important with this disease to relax muscles in a hot tub or spa." "It is important to engage in social activity, and volunteering to read to schoolchildren will keep you active." "It is important to develop a daily schedule that reduces fatigue and conserves energy." 53.A nurse is caring for a client who is postoperative immediately following a pheochromocytoma removal. Which of the following actions is the nurse's priority? Increase hydration. Monitor blood pressure. • Measure urine output. Provide a calm environment. 54.A nurse is teaching a client who has glaucoma and is to start taking timolol. Which of the following information should the nurse include? "Notify the provider if you experience a stinging sensation following administration." Para mi "Watch for a decreased heart rate while using this medication." "You can expect to develop a harmless darkening of the iris." • "This medication can cause the lashes of the affected eye to lengthen." 55.A nurse is providing teaching to a client who has a new onset of genital herpes. Which of the following statements should the nurse include in the teaching? "You are not contagious when lesions are healed." "This infection is spread through the air." "Stress can activate an outbreak." "Antiviral drugs will cure the infection." 56.A nurse is instructing a client's caregiver on how to position the client before administering tube feedings in the home. Which of the following statements by the caregiver demonstrates an understanding of the teaching?"I will allow him to assume a position of comfort." "I will elevate the head of the bed 10 degrees." "I will place him in a left side-lying position." "I will sit him up in bed." 57.A nurse is teaching a client who has asthma about using a peak ow meter. When a yellow zone meter reading appears, the nurse should instruct the client to take which of the following actions? Take another peak ow meter reading in 15 min. Take prescribed relief medication. Call for emergency transport to a hospital. Inhale through pursed lips. 58.A nurse is caring for a client who is postoperative and reports frequent leakage of small amounts of urine. The nurse notes that the client's bladder is palpable upon examination. The nurse should identify these findings as which of the following forms of incontinence? Stress Urge Functional Overow 59.A nurse is assessing a client who has tuberculosis and is taking rifampin. Which of the following findings should the nurse report as an adverse effect of the medication? Alopecia Yellowing of the sclera Report of constipation Report of insomnia 60.A nurse is caring for a client who has a cervical spinal cord injury. Which of the following interventions should the nurse include in the plan of care to prevent autonomic dyslexia? Monitor bowel movement regularity. Use a fan to promote air circulation in the client's roomTuck the top bedsheet tightly around the client's torso. Monitor for cerebrospinal fluid leakage 61.A nurse is caring for a client who is using a ventilator when the lowpressure ventilator alarm sounds. Which of the following actions should the nurse take? Suction secretions from the endotracheal tube. Check the ventilator tubing connections. Administer intravenous sedation and analgesia. Reassure the client and instruct them not to bite on the tube. 62.A nurse is caring for a client who has renal calculi. Which of the following prescriptions by the provider is the priority action for the nurse to take? Strain all urine. Schedule a retrograde pyelography. Monitor intake and output. Schedule a kidney ultrasound. 63.A nurse is providing discharge teaching to a client who is postoperative following a total hip arthroplasty. Which of the following statements by the client indicates an understanding of the teaching? "When I'm exercising, I'll include bent-leg raises." "I'll use my reaching device to help me pick up objects I drop on the oor." "I can stop physical therapy when I quit using my walker." • "I'll sleep on my back with my knees close together." 64.A nurse is providing teaching for a client who has Parkinson's disease and a new prescription for selegiline. Which of the following statements should the nurse include? "You might experience joint pain while taking this medication." "The medication cannot be combined with other antiparkinsonian agents." "Avoid eating aged cheeses or smoked meats while taking this medication." "It will take up to 2 weeks for the medication to work."65.A nurse is caring for a client who has renal failure. Which of the following arterial blood gas (ABG) results should the nurse expect? pH 7.25, HCO3 20 mEq/L, PaCO 35 mm Hg -2 pH 7.30, HCO3 22 mEq/L, PaCO 50 mm Hg -2 pH 7.50, HCO3 32 mEq/L, PaCO 45 mm Hg -2 pH 7.55, HCO3 28 mEq/L, PaCO 31 mm Hg 66.A nurse is reviewing a client's medical record prior to administering furosemide via IV bolus to a client who has heart failure. For which of the following ndings should the nurse withhold the medication and notify the provider? Hypokalemia Hypernatremia Hypoglycemia Hypermagnesemia 67.A nurse is initiating a plan of care for a client who has COPD. Which of the following interventions should the nurse include? Request a prescription for an antibiotic. Educate the client on pursed-lip breathing. Place the client in airborne precautions. Initiate a referral for gene therapy. 68.A nurse is receiving report on a group of clients. Which of the following clients should the nurse assess first? A client who has a chest tube and reports a pain level of 6 on a scale of 0 to 10 A client who received parenteral cephalosporin and reports urticaria and edema A client who is being admitted with bilateral Stage 3 pressure injuries on both heels A client who has a systemic infection and an oral temperature of 39.1° C (102.4° F)69.A nurse is discussing risk factors for hepatitis A with a newly licensed nurse. Which of the following clients should the nurse identify as being at an increased risk for hepatitis A? A client who is hepatitis B positive A client who had a kidney transplant in 1990 A client who has a history of intravenous street drug use A client who has recently done volunteer work in a developing country 70.A nurse is providing education regarding the prevention of urinary tract infections (UTIs) to a client who has a history of cystitis. Which of the following statements by the client indicates that the teaching has been effective? "I will limit my fluid intake to 1 liter per day to prevent frequency and urgency." "I will empty my bladder every 2 to 3 hours throughout the day." "I will use an antiseptic vaginal deodorant spray twice a day to reduce the bacterial growth." "I will take a hot bath after sexual intercourse." 71.A nurse is providing instructions to a newly licensed nurse about NG intubation for a client who is postoperative following a colectomy. Which of the following statements should the nurse include? "Tube drainage should be rust-colored." "Nutrition will be provided through the tube." Para mi "The tube decreases pressure within the stomach." "The tube should be irrigated with sterile water." 72.A nurse is caring for a client who has a history of tonic-clonic seizures. Which of the following precautions should the nurse take? (Select all that apply.) Keep a suction apparatus at the bedside. Keep a padded tongue blade next to the bed. Keep the bed in the lowest position. Keep oxygen equipment at the bedside. Keep safety restraints near the bedside.73.A nurse is creating a plan of care for a client who has meningitis. Which of the following interventions should the nurse include? Initiate contact isolation precautions. Keep the client's environment dark and quiet. Restrict the client's fluid intake. Perform neurovascular assessments once a day. 74.A nurse is a caring for client who is postoperative following a below-theknee amputation. Which of the following actions should the nurse take? Maintain a loose bandage on the residual limb. Turn the client from side to side once every 4 hr. Request a soft mattress for the client. Place the client prone for 20 min every 3 hr. 75.A nurse is assessing a client who has meningitis. The nurse should identify which of the following findings as a positive Kernig's sign? After stroking the lateral area of the foot, the client's toes contract and draw together. After hip exion, the client is unable to extend their leg completely without pain. Esta es la misma pregunta 17 The client's voluntary movement is not coordinated. The client reports pain and stiness when exing their neck 76. A nurse is caring for a client who has rheumatoid arthritis and has been taking prednisone. Which of the following findings should the nurse identify as an adverse effect of this medication? Weight loss Hypoglycemia Hypertension Hyperkalemia 77.A nurse is caring for a client who has increased intracranial pressure (ICP). Which of the following interventions should the nurse implement? Place several pillows behind the client's head.Place the client in a Sims' position. Keep the client's neck in a midline position. Maintain exion of the client's hips at a 90° angle 78.A nurse in a rural community center is providing education to a group of clients about first aid interventions for snake bites to prevent further injury. Which of the following instructions should the nurse include in the teaching? Apply an ice pack directly to the affected area. Immobilize the affected extremity with a splint. Place a tourniquet above and below the affected area. Elevate the affected extremity 79.A nurse is providing discharge teaching to a client who is starting to take carbidopa/levodopa to treat Parkinson's disease. Which of the following instructions should the nurse include in the teaching? "This medication can cause your urine to turn a dark color." "Expect immediate relief after taking this medication." "Take the medication with a high-protein food." "Skip a dose of the medication if you experience dizziness." 80.A nurse is providing dietary teaching for a client who has chronic cholecystitis. Which of the following diets should the nurse recommend? Low-potassium diet High-ber diet Low-fat diet Low-sodium diet 81.A nurse is providing teaching to a client who is scheduled for an electroencephalogram (EEG). Which of the following statements by the client indicates an understanding of the teaching?"I should not wash my hair prior to the procedure." "I will receive a sedative 1 hour before the procedure." "I should avoid eating prior to the procedure." "I will be exposed to ashes of light during the procedure." 82.A nurse is providing discharge teaching to a client following a heart transplant. Which of the following information should the nurse include in the teaching? Immunosuppressant medications need to be taken for up to 1 year. Shortness of breath might be an indication of transplant rejection. The surgical site will heal in 3 to 4 weeks after surgery. Begin 45 min of moderate aerobic exercise per day following discharge 83.A nurse is caring for a client who has been experiencing repeated tonicclonic seizures over the course of 30 min. After maintaining the client's airway and turning the client on their side, which of the following medications should the nurse administer? Diazepam IV Lorazepam PO Diltiazem IV Clonazepam PO 84.A nurse is providing discharge instructions to a client who has GERD. Which of the following statements by the client demonstrates an understanding of the teaching? "I should take my medicine with orange juice." "A bedtime snack will prevent heartburn." "I will lie down after meals." "I will limit activities that require bending at the waist."85.A nurse is caring for a client who is at high risk for iron deciency anemia. Which of the following foods should the nurse instruct the client to increase in their diet? Yogurt Apples Raisins Cheddar cheese 86.A nurse is caring for a client who has a right-sided pneumothorax. Following chest tube insertion, which of the following findings indicates that the chest drainage system is functioning correctly? Gentle bubbling in the suction chamber • Crepitus around the insertion site Constant bubbling in the water seal chamber Absence of breath sounds on the right side 87.A nurse is planning care for a client who has acute post-streptococcal glomerulonephritis. Which of the following interventions should the nurse include in the client's plan? Encourage a high-protein diet for the client. Increase the client's fluid intake. Administer diuretics to the client. Weigh the client twice a week. 88.A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine. Which of the following interventions should the nurse include in the plan?Inspect the pin site every 48 hr. Monitor the client's skin under the halo vest. Ensure two personnel hold the halo device when repositioning the client. Apply powder frequently to the client's skin under the vest to decrease itching. 89.Nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse identify as a possible complication of TPN administration? Pitting edema of bilateral lower extremities Hypoactive bowel sounds in all four quadrants Weight is the same as the day before Bilateral posterior lung sounds are diminished 90.A nurse is assessing a client who has a heart rate of 40/min. The client is diaphoretic and has chest pain. Which of the following medications should the nurse plan to administer? Lidocaine Adenosine Atropine Verapamil 91.A nurse is preparing to discharge a client who has a new diagnosis of chronic kidney disease (CKD). Which of the following referrals should the nurse plan to initiate? Respiratory therapy Hospice care Occupational therapyDietary services 92.A nurse is caring for a client who has burn injuries covering their upper body and is concerned about their altered appearance. Which of the following statements should the nurse make? "It is okay to not want to touch the burned areas of your body." "Cosmetic surgery should be performed within the next year to be effective." "Reconstructive surgery can completely restore your previous appearance." "It could be helpful for you to attend a support group for people who have burn injuries." 93.A nurse is caring for a client who has dehydration. The client has a peripheral IV and has a prescription for an infusion of 0.9% sodium chloride 1,000 mL with 40 mEq potassium chloride to infuse over 1 hr. Which of the following actions should the nurse take first? Teach the client to report findings of IV extravasation. Evaluate the patency of the IV. Consult with the pharmacist about the prescription. Verify the prescription with the provider 94.A nurse is admitting a client who has suspected appendicitis. Which of the following findings should the nurse report to the provider immediately? Distended, board-like abdomen WBC count 15,000/mm3 (para mi esta es la respuesta Idania) Rebound tenderness over McBurney's point Temperature 37.3° C (99.1° F)95.A nurse in an emergency department is caring for a client who has sustained multiple injuries. The nurse observes the client's thorax moving inward during inspiration and outward during expiration. The nurse should suspect which of the following injuries? Flail chest Hemothorax Pulmonary contusion Pneumothorax 96.A nurse is assessing a client who has a sodium level of 122 mEq/L. Which of the following ndings should the nurse expect? Decreased deep-tendon reexes Positive Trousseau's sign Hypoactive bowel sounds Sticky mucous membranes 97.A nurse is providing teaching to a client who is scheduled for electromyography (EMG). The nurse should include which of the following information in the teaching? "You will receive a xed dose of radioisotope 2 hours before the procedure." "Momentary ushing will occur at the beginning of the procedure." "You should inform your provider if you are claustrophobic." "You should expect insertion of small needle electrodes into the muscles." 98.A nurse is providing discharge teaching for a client who has COPD about nutrition. Which of the following instructions should the nurse include? Eat three large meals daily.Consume high-calorie foods. Limit caffeinated drinks to two per day. Drink fluids during meal time. 99.A nurse is providing discharge teaching to a client who has acute leukemia and received chemotherapy 12 hr ago. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) ✓ Use an electric shaver. ✓ Avoid crowds. Take temperature weekly. ✓ Consume a low-residue diet. ✓ Monitor for bruising. 100. A nurse is planning care for a group of postoperative clients. Which of the following interventions should the nurse identify as the priority? Administer IV pain medication to a client who reports pain as a 6 on a scale of 0 to 10. Administer oxygen to a client who has an oxygen saturation of 91%. Instruct a client who is 1 hr postoperative about coughing and deep breathing exercises. Initiate an infusion of 0.9% sodium chloride for a client who has just had abdominal surgery. 101. A nurse is caring for a client who is to undergo a liver biopsy. Which of the following instructions should the nurse provide to the client following the procedure? "Lie on your left side." "Lie on your right side.""Increase your fluid intake." "Decrease your fluid intake." 102. A nurse is assessing a client who has a permanent spinal cord injury and is scheduled for discharge. Which of the following client statements indicates that the client is coping effectively? "I would like to play wheelchair basketball. When I get stronger, I think I'll look for a league." "I'm glad I'll only be in this wheelchair temporarily. I can't wait to get back to running." "I'm so upset that this happened to me. What did I do to deserve this, and why am I not getting better?" "I feel like I'll never be able to do anything that I want to again. All I am is a burden to my family." 103. A nurse is caring for a client who has chronic kidney disease. Which of the following diets should the nurse anticipate the provider to prescribe? 4 g sodium diet Potassium-restricted diet High-phosphorous diet High-protein diet [Show Less]
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Contemporary Medical-Surgical Nursing Nicoll 2E NEW TESTBANK | COMPLETE 66 CHAPTERS | 383 PAGES
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Table of Contents 1 Chapter 01: Overview of Professional Nursing Concepts for Medical-Surgical Nursing Chapter 02: Overview of Health Concepts for Medic... [Show More] al-Surgical Nursing Chapter 03: Common Health Problems of Older Adults Chapter 04: Assessment and Care of Patients with Pain Chapter 05: Genetic Concepts for Medical-Surgical Nursing Chapter 06: Rehabilitation Concepts for Chronic and Disabling Health Problems Chapter 07: End-of-Life Care Chapter 08: Concepts of Emergency and Trauma Nursing Chapter 09: Care of Patients with Common Environmental Emergencies Chapter 10: Concepts of Emergency and Disaster Preparedness Chapter 11: Assessment and Care of Patients with Fluid and Electrolyte Imbalances Chapter 12: Assessment and Care of Patients with Acid-Base Imbalances Chapter 13: Infusion Therapy Chapter 14: Care of Preoperative Patients Chapter 15: Care of Intraoperative Patients Chapter 16: Care of Postoperative Patients Chapter 17: Inflammation and Immunity Chapter 18: Care of Patients with Arthritis and Other Connective Tissue Diseases Chapter 19: Care of Patients with HIV Disease Chapter 20: Care of Patients with Hypersensitivity (Allergy) and Autoimmunity Chapter 21: Cancer Development Chapter 22: Care of Patients with Cancer Chapter 23: Care of Patients with Infection Chapter 24: Assessment of the Skin, Hair, and Nails Chapter 25: Care of Patients with Skin Problems Chapter 26: Care of Patients with Burns Chapter 27: Assessment of the Respiratory System Chapter 28: Care of Patients Requiring Oxygen Therapy or Tracheostomy Chapter 29: Care of Patients with Noninfectious Upper Respiratory Problems Chapter 30: Care of Patients with Noninfectious Lower Respiratory Problems Chapter 31: Care of Patients with Infectious Respiratory Problems Chapter 32: Care of Critically Ill Patients with Respiratory Problems Chapter 33: Assessment of the Cardiovascular System Chapter 34: Care of Patients with Dysrhythmias Chapter 35: Care of Patients with Cardiac Problems Chapter 36: Care of Patients with Vascular Problems Chapter 37: Care of Patients with Shock Chapter 38: Care of Patients with Acute Coronary Syndromes Chapter 39: Assessment of the Hematologic System Chapter 40: Care of Patients with Hematologic Problems Chapter 41: Assessment of the Nervous System Chapter 42: Care of Patients with Problems of the CNS: The Brain Chapter 43: Care of Patients with Problems of the CNS: The Spinal Cord Chapter 44: Care of Patients with Problems of the Peripheral Nervous System Chapter 45: Care of Critically Ill Patients with Neurologic Problems Chapter 46: Assessment of the Eye and Vision Chapter 47: Care of Patients with Eye and Vision Problems Chapter 48: Assessment and Care of Patients with Ear and Hearing Problems Chapter 49: Assessment of the Musculoskeletal System Chapter 50: Care of Patients with Musculoskeletal Problems Chapter 51: Care of Patients with Musculoskeletal Trauma Chapter 52: Assessment of the Gastrointestinal System Chapter 53: Care of Patients with Oral Cavity Problems Chapter 54: Care of Patients with Esophageal Problems Chapter 55: Care of Patients with Stomach Disorders Chapter 56: Care of Patients with Noninflammatory Intestinal Disorders Chapter 57: Care of Patients with Inflammatory Intestinal Disorders Chapter 58: Care of Patients with Liver Problems Chapter 59: Care of Patients with Problems of the Biliary System and Pancreas Chapter 60: Care of Patients with Malnutrition: Undernutrition and Obesity Chapter 61: Assessment of the Endocrine System Chapter 62: Care of Patients with Pituitary and Adrenal Gland Problems Chapter 63: Care of Patients with Problems of the Thyroid and Parathyroid Glands Chapter 64: Care of Patients with Diabetes Mellitus Chapter 65: Assessment of the Renal/Urinary System Chapter 66: Care of Patients with Urinary Problems Chapter 67: Care of Patients with Kidney Disorders Chapter 68: Care of Patients with Acute Kidney Injury and Chronic Kidney Disease Chapter 69: Assessment of the Reproductive System Chapter 70: Care of Patients with Breast Disorders Chapter 71: Care of Patients with Gynecologic Problems Chapter 72: Care of Patients with Male Reproductive Problems Chapter 73: Care of Transgender Patients Chapter 74: Care of Patients with Sexually Transmitted Diseases [Show Less]
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Med surg HESI EXIT EXAM|Updated (2021) Test Bank
1. Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat ... [Show More] and protect his ulcer. What is the best follow-up action by the nurse? Review with the client the need to avoid foods that are rich in milk and cream 2. A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him “feel bad”. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition? 3. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement? 4. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement? 5. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement? 6. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement? Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows. 7. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up? Describes life without purpose 8. A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information should the nurse include in the client’s teaching plan? Further evaluation involving surgery may be needed 9. A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan? Teach tracheal suctioning techniques 10. In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client’s respiratory rate is 14 breaths / minute. What action should the nurse implement? Document the assessment data Rational: reservoir bag should not deflate completely during inspiration and the client’s respiratory rate is within normal limits. 11. During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate firs? Respiratory apnea of 30 seconds 12. During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should the nurse take first? Check the client for lacerations or fractures 13. At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first? Inform the anesthesia care provider 14. After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take first? Listen with the bell at the same location 15. A 66-year-old woman is retiring and will no longer have a health insurance through her place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs? Medicare 16. A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline? Toasted wheat bread and jelly 17. Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse that the client is experiencing a complication? “I have a headache that gets worse when I sit up” “I am having pain in my lower back when I move my legs” “My throat hurts when I swallow” “I feel sick to my stomach and am going to throw up” 18. An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement? Obtain a clean catch mid-stream specimen 19. The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the child’s dietary restrictions. Which foods are contraindicated for this child? Foods sweetened with aspartame 20. Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide? Direct the nurse to continue the surgical hand scrub for a 5 minute duration 21. Which breakfast selection indicates that the client understands the nurse’s instructions about the dietary management of osteoporosis? Bagel with jelly and skim milk22. The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse (RN)? An 82-year-old client with Alzheimer’s disease newly-fractures femur who has a Foley catheter and soft wrist restrains applied 23. A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician’s office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child’s foot. Which action should the nurse implement first? Cleanse the foot with soap and water and apply an antibiotic ointment Provide teaching about the need for a tetanus booster within the next 72 hours. have the mother check the child's temperature q4h for the next 24 hours transfer the child to the emergency department to receive a gamma globulin injection 24. The mother of an adolescent tells the clinic nurse, “My son has athlete’s foot, I have been applying triple antibiotic ointment for two days, but there has been no improvement.” What instruction should the nurse provide? Stop using the ointment and encourage complete drying of the feet and wearing clean socks. 25. A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences Bradycardia and constipation Lethargy and lack of appetite Muscle cramping and dry, flushed skin Palpitations and shortness of breath 26. A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and palpitations. Which finding is most important for the nurse to assess to the client? Obtain a list of medications taken for cardiac history 27. The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only.) 75 Rationale: Convert mg to mcg and use the formula D/H x Q. 300 mcg/hour / 1,000 mcg x 250 ml = 3/1 x 25 = 75 ml/hour 28. The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that apply) Fluid shifts from intravascular to interstitial area due to decreased serum protein Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen Increased circulating aldosterone levels that increase sodium and water retention 29. The nurse is auscultating a client’s heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio first to select the option that applies) Murmur Rationale: A murmur is auscultated as a swishing sound that is associated with the blood turbulence created by the heart or valvular defect. 30. The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant. The 500 mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration of 100 mg/ml. How many ml should the nurse administered for each dose? (Enter numeric value only. If rounding is required, round to the nearest tenth) 0.4 rationale: 35mg/100mg x 1 = 0.35 = 0.4 ml 31. The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete? Auscultate the client's bowel sounds Observe for edema around the ankles Measure the client’s capillary glucose level Count the apical and radial pulses simultaneously Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis and frequently causes constipation, so it is most important to Auscultate the client's bowel sounds 32. A female client is admitted with end stage pulmonary disease is alert, oriented, and complaining of shortness of breath. The client tells the nurse that she wants “no heroic measures” taken if she stops breathing, and she asks the nurse to document this in her medical record. What action should the nurse implement? Ask the client to discuss “do not resuscitate” with her healthcare provider 33. A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What intervention should the nurse implement? Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour 34. A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the nurse to ask? Have you noticed any changes in your fingernails? Rationale: The pattern of reported manifestations is suggestive of hypothyroidism 35. After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse? Capillary refill of 8 seconds bruises on arms and legs round and tight abdomen pitting edema in lower legs 36. After the nurse witnesses a preoperative client sign the surgical consent form, the nurse signs the form as a witness. What are the legal implications of the nurse’s signature on the client’s surgical consent form? (Select all that apply) The client voluntarily grants permission for the procedure to be done The client is competent to sign the consent without impairment of judgment The client understands the risks and benefits associated with the procedure 37. Following surgery, a male client with antisocial personality disorder frequently requests that a specific nurse be assigned to his care and is belligerent when another nurse is assigned. What action should the charge nurse implement? Advise the client that assignments are not based on clients requests 38. A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take? Place the implant in a lead container using long-handled forceps 39. The client with which type of wound is most likely to need immediate intervention by the nurse? Laceration Abrasion Contusion Ulceration Rationale: A laceration is a wound that is produced by the tearing of soft body tissue. This type of wound is often irregular and jagged. A laceration wound is often contaminated with bacteria and debris from whatever object caused the cut. 40. The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client’s plan of care? Monitor blood pressure frequently Rationale: A pheochromocytoma is a rare, catecholamine-secreting tumor that may precipitate life-threatening hypertension. The tumor is malignant in 10% of cases but may be cured completely by surgical removal. Although pheochromocytoma has classically been associated with 3 syndromes—von Hippel-Lindau (VHL) syndrome, multiple endocrine neoplasia type 2 (MEN 2), and neurofibromatosis type 1 (NF1)—there are now 10 genes that have been identified as sites of mutations leading to pheochromocytoma. 41. When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention? To reduce abdominal pressure on the diaphragm to promote retraction of the intercostal accessory muscle of respiration to promote bronchodilation and effective airway clearance to decrease pressure on the medullary center which stimulates breathing Rationale: a semi-sitting position is the best position for matching ventilation and perfusion and for decreasing abdominal pressure on the diaphragm, so that the client can maximize breathing. 42. When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely explanation for failure to locate the gallbladder by palpation? The client is too obese Palpating in the wrong abdominal quadrant Deeper palpation technique is needed The gallbladder is normal Rationale: a normal healthy gallbladder is not palpable 43. A woman with an anxiety disorder calls her obstetrician’s office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman? describe the transmission of drugs to the infant through breast milk encourage her to use stress relieving alternatives, such as deep breathing exercises Inform her that some antianxiety medications are safe to take while breastfeeding Explain that anxiety is a normal response for the mother of a 3-week-old. Rationale: there are several antianxiety medications that are not contraindicated for breastfeeding mothers. 44. An older male client with a history of type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first? Start an intravenous (IV) infusion of normal saline obtain a serum potassium level administer the client's usual dose of insulin assess pupillary response to light Rationale: the nurse should first start an intravenous infusion of normal saline to replace the fluids and electrolytes because the client has been vomiting, and it is unclear when he last ate or took insulin. The symptoms of confusion, lethargy, vomiting, and abdominal cramping are all suggestive of hyperglycemia, which also contributes to diuresis and fluid electrolyte imbalance. 45. A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse’s decision to hold the client’s scheduled antihypertensive medication? increased urinary clearance of the multiple medications has produced diuresis and lowered the blood pressure the antagonistic interaction among the various blood pressure medications has reduced their effectiveness The additive effect of multiple medications has caused the blood pressure to drop too low the synergistic effect of the multiple medications has resulted in drug toxicity and resulting hypotension 46. Which client is at the greatest risk for developing delirium? An adult client who cannot sleep due to constant pain. an older client who attempted 1 month ago a young adult who takes antipsychotic medications twice a day a middle-aged woman who uses a tank for supplemental oxygen 47. Which intervention should the nurse include in a long-term plan of care for a client withChronic Obstructive Pulmonary Disease (COPD)? Reduce risks factors for infection Administer high flow oxygen during sleep Limit fluid intake to reduce secretions Use diaphragmatic breathing to achieve better exhalation 48. Which location should the nurse choose as the best for beginning a screening program for hypothyroidism? A business and professional women's group. An African-American senior citizens center A daycare center in a Hispanic neighborhood An after-school center for Native-American teens 49. A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling “very tired”. Which nursing intervention is most important for the nurse to implement? Measure vital signs Auscultate breath sounds Palpate the abdomen Observe the skin for bruising 50. A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab is important for the nurse to review before contacting the health care provider? capillary glucose urine specific gravity Serum calcium [Show Less]
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Med surg HESI EXIT EXAM|Updated (June 2021) Test Bank.
1. Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat ... [Show More] and protect his ulcer. What is the best follow-up action by the nurse? Review with the client the need to avoid foods that are rich in milk and cream 2. A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him “feel bad”. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition? 3. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement? 4. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement? 5. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement? 6. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement? Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows. 7. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up? Describes life without purpose 8. A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information should the nurse include in the client’s teaching plan? Further evaluation involving surgery may be needed 9. A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan? Teach tracheal suctioning techniques 10. In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client’s respiratory rate is 14 breaths / minute. What action should the nurse implement? Document the assessment data Rational: reservoir bag should not deflate completely during inspiration and the client’s respiratory rate is within normal limits. 11. During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate firs? Respiratory apnea of 30 seconds 12. During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should the nurse take first? Check the client for lacerations or fractures 13. At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first? Inform the anesthesia care provider 14. After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take first? Listen with the bell at the same location 15. A 66-year-old woman is retiring and will no longer have a health insurance through her place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs? Medicare 16. A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline? Toasted wheat bread and jelly 17. Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse that the client is experiencing a complication? “I have a headache that gets worse when I sit up” “I am having pain in my lower back when I move my legs” “My throat hurts when I swallow” “I feel sick to my stomach and am going to throw up” 18. An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement? Obtain a clean catch mid-stream specimen 19. The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the child’s dietary restrictions. Which foods are contraindicated for this child? Foods sweetened with aspartame 20. Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide? Direct the nurse to continue the surgical hand scrub for a 5 minute duration 21. Which breakfast selection indicates that the client understands the nurse’s instructions about the dietary management of osteoporosis? Bagel with jelly and skim milk22. The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse (RN)? An 82-year-old client with Alzheimer’s disease newly-fractures femur who has a Foley catheter and soft wrist restrains applied 23. A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician’s office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child’s foot. Which action should the nurse implement first? Cleanse the foot with soap and water and apply an antibiotic ointment Provide teaching about the need for a tetanus booster within the next 72 hours. have the mother check the child's temperature q4h for the next 24 hours transfer the child to the emergency department to receive a gamma globulin injection 24. The mother of an adolescent tells the clinic nurse, “My son has athlete’s foot, I have been applying triple antibiotic ointment for two days, but there has been no improvement.” What instruction should the nurse provide? Stop using the ointment and encourage complete drying of the feet and wearing clean socks. 25. A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences Bradycardia and constipation Lethargy and lack of appetite Muscle cramping and dry, flushed skin Palpitations and shortness of breath 26. A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and palpitations. Which finding is most important for the nurse to assess to the client? Obtain a list of medications taken for cardiac history 27. The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only.) 75 Rationale: Convert mg to mcg and use the formula D/H x Q. 300 mcg/hour / 1,000 mcg x 250 ml = 3/1 x 25 = 75 ml/hour 28. The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that apply) Fluid shifts from intravascular to interstitial area due to decreased serum protein Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen Increased circulating aldosterone levels that increase sodium and water retention 29. The nurse is auscultating a client’s heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio first to select the option that applies) Murmur Rationale: A murmur is auscultated as a swishing sound that is associated with the blood turbulence created by the heart or valvular defect. 30. The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant. The 500 mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration of 100 mg/ml. How many ml should the nurse administered for each dose? (Enter numeric value only. If rounding is required, round to the nearest tenth) 0.4 rationale: 35mg/100mg x 1 = 0.35 = 0.4 ml 31. The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete? Auscultate the client's bowel sounds Observe for edema around the ankles Measure the client’s capillary glucose level Count the apical and radial pulses simultaneously Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis and frequently causes constipation, so it is most important to Auscultate the client's bowel sounds 32. A female client is admitted with end stage pulmonary disease is alert, oriented, and complaining of shortness of breath. The client tells the nurse that she wants “no heroic measures” taken if she stops breathing, and she asks the nurse to document this in her medical record. What action should the nurse implement? Ask the client to discuss “do not resuscitate” with her healthcare provider 33. A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What intervention should the nurse implement? Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour 34. A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the nurse to ask? Have you noticed any changes in your fingernails? Rationale: The pattern of reported manifestations is suggestive of hypothyroidism 35. After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse? Capillary refill of 8 seconds bruises on arms and legs round and tight abdomen pitting edema in lower legs 36. After the nurse witnesses a preoperative client sign the surgical consent form, the nurse signs the form as a witness. What are the legal implications of the nurse’s signature on the client’s surgical consent form? (Select all that apply) The client voluntarily grants permission for the procedure to be done The client is competent to sign the consent without impairment of judgment The client understands the risks and benefits associated with the procedure 37. Following surgery, a male client with antisocial personality disorder frequently requests that a specific nurse be assigned to his care and is belligerent when another nurse is assigned. What action should the charge nurse implement? Advise the client that assignments are not based on clients requests 38. A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take? Place the implant in a lead container using long-handled forceps 39. The client with which type of wound is most likely to need immediate intervention by the nurse? Laceration Abrasion Contusion Ulceration Rationale: A laceration is a wound that is produced by the tearing of soft body tissue. This type of wound is often irregular and jagged. A laceration wound is often contaminated with bacteria and debris from whatever object caused the cut. 40. The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client’s plan of care? Monitor blood pressure frequently Rationale: A pheochromocytoma is a rare, catecholamine-secreting tumor that may precipitate life-threatening hypertension. The tumor is malignant in 10% of cases but may be cured completely by surgical removal. Although pheochromocytoma has classically been associated with 3 syndromes—von Hippel-Lindau (VHL) syndrome, multiple endocrine neoplasia type 2 (MEN 2), and neurofibromatosis type 1 (NF1)—there are now 10 genes that have been identified as sites of mutations leading to pheochromocytoma. 41. When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention? To reduce abdominal pressure on the diaphragm to promote retraction of the intercostal accessory muscle of respiration to promote bronchodilation and effective airway clearance to decrease pressure on the medullary center which stimulates breathing Rationale: a semi-sitting position is the best position for matching ventilation and perfusion and for decreasing abdominal pressure on the diaphragm, so that the client can maximize breathing. 42. When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely explanation for failure to locate the gallbladder by palpation? The client is too obese Palpating in the wrong abdominal quadrant Deeper palpation technique is needed The gallbladder is normal Rationale: a normal healthy gallbladder is not palpable 43. A woman with an anxiety disorder calls her obstetrician’s office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman? describe the transmission of drugs to the infant through breast milk encourage her to use stress relieving alternatives, such as deep breathing exercises Inform her that some antianxiety medications are safe to take while breastfeeding Explain that anxiety is a normal response for the mother of a 3-week-old. Rationale: there are several antianxiety medications that are not contraindicated for breastfeeding mothers. 44. An older male client with a history of type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first? Start an intravenous (IV) infusion of normal saline obtain a serum potassium level administer the client's usual dose of insulin assess pupillary response to light Rationale: the nurse should first start an intravenous infusion of normal saline to replace the fluids and electrolytes because the client has been vomiting, and it is unclear when he last ate or took insulin. The symptoms of confusion, lethargy, vomiting, and abdominal cramping are all suggestive of hyperglycemia, which also contributes to diuresis and fluid electrolyte imbalance. 45. A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse’s decision to hold the client’s scheduled antihypertensive medication? increased urinary clearance of the multiple medications has produced diuresis and lowered the blood pressure the antagonistic interaction among the various blood pressure medications has reduced their effectiveness The additive effect of multiple medications has caused the blood pressure to drop too low the synergistic effect of the multiple medications has resulted in drug toxicity and resulting hypotension 46. Which client is at the greatest risk for developing delirium? An adult client who cannot sleep due to constant pain. an older client who attempted 1 month ago a young adult who takes antipsychotic medications twice a day a middle-aged woman who uses a tank for supplemental oxygen 47. Which intervention should the nurse include in a long-term plan of care for a client withChronic Obstructive Pulmonary Disease (COPD)? Reduce risks factors for infection Administer high flow oxygen during sleep Limit fluid intake to reduce secretions Use diaphragmatic breathing to achieve better exhalation 48. Which location should the nurse choose as the best for beginning a screening program for hypothyroidism? A business and professional women's group. An African-American senior citizens center A daycare center in a Hispanic neighborhood An after-school center for Native-American teens 49. A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling “very tired”. Which nursing intervention is most important for the nurse to implement? Measure vital signs Auscultate breath sounds Palpate the abdomen Observe the skin for bruising 50. A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab is important for the nurse to review before contacting the health care provider? capillary glucose urine specific gravity Serum calcium white blood cell count [Show Less]
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Med Surg 3-Graded A+
EVERYTHING CORRECT 1. A nurse is assessing a client who is 12hr postoperative following a colon resection. Which of the following findings should the nur... [Show More] se report to the surgeon? a. Heart rate 90/min b. Absent bowel sounds c. Hgb 8.2 g/dl d. Gastric pH of 3.0 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 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 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 ondansetron. 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 fentanylb. Intramuscular meperidine c. Oral acetaminophen d. Intravenous dexamethasone 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 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 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 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 Hg10. 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 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 b. Hypoglycemia c. Hypoalbuminemia d. Decreased Hematocrit 12. A nurse is caring for a client who has dumping syndrome following a gastrectomy, which of the following actions should the nurse takes? a. Offer the client high carbohydrate meal options b. Provide the client with four full meals a day c. Encourage the client to drink at least 360 ml of fluids with meals d. Have the client lie down for 30 minutes after meals 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 a. Born with a high weight b. Chronic infections of the middle ear c. Use a loop diuretic such as furosemide and antibiotics like aminoglycoside and gentamicin d. Perforation of the ear drum e. Frequent exposure to low volume noise 14. A nurse is preparing to administer fresh frozen plasma to a client. Which of the following actions should the nurse take?a. Administer the plasma immediately after thawing b. Transfuse the plasma over 4 hours c. Hold the transfusion if the client is actively bleeding d. Administer the transfusion through a 24-gauge saline lock 15. A nurse is assessing a client who reports numbness and tingling of his toes and exhibits a positive trousseau. Which of the following electrolyte imbalance should the nurse suspect? a. Hyponatremia b. Hyperchloremia c. Hypermagnesemia d. Hypocalcemia 16. A home health nurse is teaching a client how to care for a peripherally central catheter in his right arm. Which of the following statements should the nurse include in the teaching? a. Change the transparent dressing over the insertion site every 48 hours b. Clean the insertion site with mild soap and water c. Measure your right arm circumference once weekly d. Use a 10milliliter syringe when flushing the catheter 17. A nurse is caring for a client who has a central venous access device. Which of the following assessment findings should the nurse report to the provider? a. RBC count of 4.7 million/mm b. BUN 22-mg/ dl c. WBC count of 16,000/ mm d. Blood glucose of 120 mg/dl 18. A nurse is providing dietary teaching to a client who has chronic kidney disease and a decreased glomerular filtration rate. Which of the following statements by the client indicates an understanding of the teaching? a. I will spread my protein allowances over the entire day b. I should increase my intake of canned salmon to three times per week c. I will season my food with lemon pepper rather than salt d. I should limit my intake of hard cheese to 3 ounces each day19. A nurse is caring for a client who has a peripherally inserted central catheter. The client is receiving an antibiotic via intermittent IV bolus. Which of the following actions should the nurse take? a. Administer 20 ml of 0.9 sodium chloride after each dose of medication b. Flush the catheter using a 5 ml syringe c. Verify the placement with an x-ray prior to the initial dose d. Change the transparent membranes dressing daily 20. A nurse is teaching a client using a metered dose rescue inhaler. Which of the following statements should the nurse include in the teaching? a. Do not shake your inhaler before use. b. Exhale fully before bringing the inhaler to your lips c. Depress the canister after you inhale d. Use peroxide to clean the mouthpiece if your inhaler 21. A nurse is assessing the pain status of a group of clients. Which of the following findings indicate a client is experiencing referred pain? a. A client who has angina reports substernal chest pain b. A client who has pancreatitis reports pain in the left shoulder c. A client who is postoperative reports incisional pain d. A client who has peritonitis reports generalized abdominal pain 22. A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia. Which of the following assessments findings requires immediate intervention by the nurse? a. The client reports a pain level of 7 on a scale from 0 -10 at the operative site. b. The client’s capillary refill in the left toe is 6 c. The client has an oral temperature of 38.3 (100.9 F) d. The client has 1 [Show Less]
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ATI Med-Surg proctored Exam 2021/2022-Rated A+
1. The nurse is preparing the discontinue long term TPN therapy for a client. The nurse should plan to discontinue the TPN gradually to reduce the risk of... [Show More] which of the following adverse effects? a. Hyperglycemia b. Diarrhea c. Constipation d. Hypoglycemia- You taper it off to avoid this!!! Rationale PDF p.298: Never abruptly stop TPN. Speeding up/slowing down the rate is contraindicated. An abrupt rate change can alter blood glucose levels significantly. Rationale PDF nutrition p.58: don’t discontinue abruptly, must taper to prevent rebound hypoglycemia 2. A nurse is preparing a client for an ECG. The client is anxious and says that he is afraid the equipment will give him an electric shock. Which of the following is an appropriate response by the nurse? a. The machine only senses and records electrical currents coming from your heart – pg.170 Electrocardiography uses an electrocardiograph to record the electrical activity of the heart over time. b. The lead wires and cables are insulated for your safety c. The electrode pads will prevent the conduction of electricity to your skin d. The machine voltage delivery is low enough that you won’t feel any discomfort 3. A nurse is caring for client who has hypertension and has a new prescription for lisinopril. The nurse should consult with the provider about which of the following medications in the client’s medication administration record? a. Potassium chloride b. Levothyroxine c. Acetaminophen d. Metformin 4. A nurse is administering furosemide 80 mg PO twice daily to a client who has pulmonary edema. Which of the following assessment findings indicates to the nurse that the medication is effective? a. Elevation in blood pressure b. Adventitious breath sounds c. Weight loss of 1.8 kg (4 lb) in the past 24 hr d. Respiratory rate of 24/min 5. Couldn't paste the picture on here. But it asked where u can hear pericardial friction rub the best at… Erb’s Point (3rd Intercostal, Central) 6. A nurse is completing discharge teaching with a client who has a new diagnosis of AIDS. Which of the following statements by the nurse indicates an understanding of the teaching?a. I will increase the amount of fresh veggies b. I will wipe up areas soiled with body fluids with alcohol and immediately dispose of the trash c. I will need to take my clothes to the dry cleaners to sterilize them d. I will be sure to wear gloves and wash my hands when I change my cat’s litter box 7. A nurse is performing a venipuncture on an older adult client whose veins are difficult. Which of the following actions should the nurse take? a. Apply cool compresses b. Elevate the client’s extremity using a pillow c. Tap the skin around the insertion site d. Raise the angle of the catheter to 30 degrees above the insertion site 8. A nurse is caring for a client in the ER following a myocardial infarction. which of the following actions should the nurse anticipate if the client develops asystole? a. Administer atropine b. Defibrillate with 200 joules c. Starts a continuous lidocaine infusion d. Begin CPR – first line of medical management is CPR and ACLS. 9. A nurse is caring for a client with severe burn injury. The nurse should recognize which of the following client findings as an indication of hypovolemic shock? a. Potassium 5.2 mEq/L b. Capillary refill 1.5 seconds c. Urine output 45 mL/hr d. PaCO3 37 mmHg 10. 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? a. 2 b. 5 c. 10 d. 13 11. A nurse is teaching a client who has heart failure about self-management techniques. Which of the following statements by the client indicates an understanding of the teaching? a. I will keep an exercise diary b. I will take ibuprofen for mild painc. I will expect swelling in my feet and ankle d. I will weigh myself every other day 12. A nurse is providing discharge teaching for a client who has new tracheostomy. Which of the following statements by the client indicates an understanding of the teaching a. I’ll insert the obturator after cleaning my stoma b. I’ll cut a slit in a clean gauze pad to use as a stoma dressing c. I’ll cleanse the cannula with half strength hydrogen peroxide d. I’ll remove the soiled tracheostomy ties prior to cleaning my stoma 13. A nurse is caring for a client who has a sealed radiation implant which of the following actions should the nurse take? a. Limit family member visits to 30 min per day – pg. 583 Limit visitors to 30-min visits, and have visitors maintain 6 feet distance from the source b. Give the dosimeter badge to the oncoming nurse at the end of the shift c. Apply second pair of gloves before touching the clients implant if it dislodges d. Remove soiled linens from the room after each change 14. A nurse is reviewing the medical record of a client who has pneumonia. Which of the following serum laboratory values should the nurse expect? a. WBC count 15,000/mm b. Hematocrit 35% c. Sodium 130 mg/dl d. BUN 8 mg/dl 15. A nurse is planning care for a client who has a newly implanted arteriovenous graft in the right arm. Which of the following actions should the nurse include in the plan of care? a. Instruct the client to avoid lifting the right arm for 72 hr b. Check blood pressure in the right arm c. Palpate the site for thrill d. Insert a saline lock into a site 10 cm (4in) distal to the graft 16. A nurse in the emergency department is caring for a client who has a gunshot wound to the abdomen. which of the following should the nurse take first? a. Check the color of the client’s skin – Assessment first b. Prepare the client’s clothing c. Remove all the clients clothing d. Administer an opioid analgesic17. A nurse is assessing a client who has an arteriovenous (AV) fistula in the left forearm. Which of the following findings should the nurse identify as an indication of a complication at the vascular access site? a. Presence of palpable thrill b. 2 + left radial pulse c. Absence of bruit – pg. 367 d. Dilated appearance of the AV site 18. A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. The client reports spasms and the nurse observes decreased urinary output. Which of the following actions should the nurse take? a. Decrease traction on the catheter b. Remove the indwelling urinary catheter c. Flush the catheter manually with 0.9% sodium chloride d. Administer ibuprofen 400 mg for pain relief 19. A nurse is caring for a client who has contusion of the brainstem and reports thirst. The client’s urinary output was 4,000 mL over the past 24 hr. The nurse should anticipate a prescription for which of the following IV medications? a. Desmopressin – pg.500 Desmopressin, which is a synthetic ADH, or aqueous vasopressin administered intranasally, orally, or parenterally. Results in increased water absorption from kidneys and decreased urine output. b. Epinephrine c. Furosemide d. Nitroprusside 20. A nurse is preparing to administer daily medications to a client who is undergoing a procedure at 1000 that requires IV contrast dye. Which of the following routine medications to give at 0800 should the nurse withhold? a. Valproic acid b. Metformin – pg.530 c. Metoprolol d. Fluticasone Stop Metformin for 48 hr before any type of elective radiographic test with iodinated contrast dye and restart 48 hr after (can cause lactic acidosis due to acute kidney injury).21. A nurse is preparing a client who is to undergo a thoracentesis. The nurse should place the client in which of the following positions? a. On her affected side with her head lowered b. In high-Fowler’s position with her arms at her side c. Prone position with her arms above her head d. Upright on the edge of the bed leaning over the bedside table 22. A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching? a. Position the mouthpiece 2.5 cm (1in) from the mouth b. Hold breaths 3 to 5 seconds before exhaling c. Place hands on the upper abdomen during inhalation d. Exhale slowly through pursed lips 23. A nurse is caring for a client who is 2 days postoperative following abdominal surgery and has a prescription for opioid analgesia. Which of the following actions should the nurse implement to help facilitate the client’s recovery? a. Provide analgesic medication prior to physical activities b. Inform the client to monitor for loose stools while taking opioid analgesia c. Withhold analgesic medication unless the client reports pain d. Administer naloxone if the client’s respiratory rate is greater than 24/min Give analgesic to relieve pain before getting involved in any physical activity 24. A nurse is preparing to assist the provider with thoracentesis for a client who has left pleural effusion. Which of the following interventions is the priority for the nurse? a. Describe the sensation the client will feel during the procedure b. Reinforce the importance of lying still during the procedure c. Administer a sedative medication d. Determine whether the client has an allergy to local anesthetics - Assessment 25. A nurse is reviewing the medical record of a client who has nephrotic syndrome. Which of the following findings should the nurse expect? a. Decreased serum lipid levels b. Proteinuria c. Hypoalbuminemia d. Decreased coagulation Nephrotic syndrome is a kidney disorder characterized by massive proteinuria, hypoalbuminemia, edema, and elevated serum lipids, anorexia, and pallor.26. A nurse is planning care for a client following a cardiac catheterization. Which of the following actions should the nurse take? a. Limit the client’s fluid intake to 1 L per day b. Keep the client on bed rest for 24 hr c. Change the client’s dressing every 8 hr d. Maintain the client’s affected extremity in extension 27. A nurse is caring for a client who has a traumatic brain injury. The client, who has been quiet and cooperative, becomes agitated and restless. Which of the following assessments should the nurse perform first? a. Urinary output b. Motor responses – pg.75 c. Blood pressure d. Blood glucose 28. 61. A nurse is providing discharge teaching to a client who has systemic lupus erythematosus. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply) a. I will use NSAIDS to treat aches and pains – pg.561 b. I will use cosmetics without moisturizer c. I will disinfect skin lesions with rubbing alcohol d. I will wear long sleeve when outdoor e. I will increase my intake of sodium CLIENT EDUCATION ●● Avoid UV and prolonged sun exposure. Use sunscreen when outside and exposed to sunlight. ●● Use mild protein shampoo and avoid harsh hair treatments. ●● Use steroid creams for skin rash. ●● Report peripheral and periorbital edema promptly. [Show Less]
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Med Surg 1 2021-Graded A+
A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? a. Bradycardia b. Flushed skin ... [Show More] c. Frothy sputum – pg.198 d. Jugular vein distention 2. A nurse is assessing a client who is experiencing renal colic from a calculus in left renal pelvis. Identify the area where the nurse should expect the client to have referred pain. (Find “hot spots” in the artwork) - CORRECT 3. A nurse is caring for a client who is receiving peritoneal dialysis and notes a decrease in the dialysate flow rate. Which of the following actions should the nurse take? (Select all the apply.) a. Monitor the access site for drainage. b. Strip the catheter tubing c. Measure the amount of the dialysate outflow d. Raise the client to high fowlers position - pg.370: encourage client to lie Supine with head slightly elevated during CCPD and APD treatment.e. Position the client to her other side. 4. A nurse is providing discharge 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? a. Wash you’r perineal area two times each day with antimicrobial soap. b. Change your pet’s litter box daily. c. Change the water in your drinking glass every 4 hrs. d. Wash your toothbrush in the dishwasher once each month. 5. A nurse is planning to insert an indwelling catheter for a female client. Which of the following actions should the nurse plan to take? a. Collect urine specimen from the drainage bag 1 hr after insertion b. Raise the head of the bed to 45 degrees prior to insertion c. Secure the catheter to the client's inner thigh d. Attach the bag to the rail of the bed 6. A nurse is providing teaching for a client who has age-related macular degeneration. Which of the following information should the nurse include in the teaching? a. A possible cause of this problem is long-term lack of dietary protein. b. You probably have a Detachment of your retina. c. You probably have noticed a decline in your central vision. – pg.63 d. The doctor can perform surgery to correct the start paying the folds in your retina. 7. A nurse is assessing a client who has cirrhosis. Which of the following findings is the priority for the nurse to report? – Expected Findings: fatigue, Wt loss, abdo.pain, abdo.distention, pruritus. a. Platelets 70,000/mm3 - pg.357 b. Distended abdomen c. Alkaline phosphatase 125 units/L d. Clay colored stools8. A nurse is preparing to discontinue long-term total parenteral nutrition (TPN) therapy for a client for a client. The nurse should plan to discontinue the TPN gradually to reduce the risk of which of the following adverse effects? a. Hyperglycemia – if unavailable, do not attempt to catch up by increasing the infusion rate because client can develop Hyperglycemia. b. Diarrhea c. Constipation d. Hypoglycemia – pg.298 – sudden abruption of infusing rate can cause hypoglycemia. 9. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse plan to take? - CORRECT a. Administer the unit of packed RBC’s over 1 hr. b. Obtain the client’s first set of vital signs 1 hr after initiating the transfusion. c. Initiate venous access with a 21-gauge needle. d. Use Y tubing with 0.9% sodium chloride when administering the transfusion. 10. A nurse is caring for a female who has toxic shock syndrome. Which of the following findings should the nurse expect? a. Elevated platelet count b. Generalized rash ■ Whole body rash c. Decreased total bilirubin d. Hypertension ■ Hypotension 11. A nurse is providing discharge teaching to an older adult client who had an exacerbation of COPD. The client is to start fluticasone by metered-dose inhaler. Which of the following instructions should the nurse include? a. Use fluticasone as needed for shortness of breath. b. Limit fluid intake to 1 L per day. c. Obtain a yearly influenza immunization. d. Assist use of pursed-lip breathing.12. A nurse is providing discharge teaching to an older adult client following a left total hip arthroplasty. Which of the following instructions should the nurse include in the teaching? a. “You can cross your legs at the ankles when sitting down.” b. “Clean the incision daily with hydrogen peroxide.” c. “Install a raised toilet seat in your bathroom.” d. “You should use an incentive spirometer every 8 hrs.” 13. Missing [Show Less]
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ATI Med-Surg proctored Exam 2021 Questions & Answers A+ Grade
ATI Med-Surg proctored Exam 2021 Questions & Answers A+ Grade
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ATI Med-Surg proctored Exam 2021/2022-Rated A+
ATI Med-Surg proctored Exam 2021/2022-Rated A+
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ATI Med-Surg proctored Exam 2021/2022-Rated A+
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... [Show More] 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. 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.. 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. 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 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 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." 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 clien [Show Less]
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