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ATI RN MEDICAL SURGICAL EXAMS & STUDY GUIDE BUNDLE | 100% Verified Rated A+
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ATI RN MEDICAL SURGICAL PROCTORED EXAM
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 tachyca... [Show More] rdia because of a failing ventricle, SNS is activated to compensate. b. Flushed skin- it will look like dusky 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 arrest, 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 that 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 symptoms 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 a lot in old people. Symptoms: 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? Pg. 357 Ch. 55 pdf Med surg a. Platelets 70,000/mm3- risk of bleed normal range is 150,000 - 300,000- 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 pg. 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 decreases inflammation but also depress our immune system. So getting a flu shot is priority. Commented [WU1]: 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 turning 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 pain 15. A nurse is planning care for a client who Clostridium difficile gastroenteritis. Which of the following is an appropriate nursing action? Pg. 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 border is always non sterile so its ok to touch it . b. Select a work surface at the nurses waist level- body mechanics. 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 pg. 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. [Show Less]
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ATI RN MEDICAL SURGICAL PROCTORED EXAM 2019
RN ATI MEDICAL SURGICAL EXAM 2019 A nurse is planning care for a client who has a full-thickness burns on the lower extremities. Which of the following i... [Show More] nterventions should the nurse include? a) Limit visitation time for client’s children to 40 minutes per day b) clean the equipment in the client's room once per week c) provide a diet of fresh fruits and vegetable for the client d) apply new gloves when alternating between wound care sites A nurse is caring for a client who has cancer. The client tells the nurse, “I would prefer to try vitamins and minerals instead of chemotherapy” which of the following responses should the nurse make? a) I have never heard of any holistic treatment that is effective b) you should ask your provider about your plan c) the best way to treat your cancer is chemotherapy d) tell me what you know about chemotherapy A nurse is planning to teach a client whose provider has prescribed a low purine diet. The nurse should plan to instruct the client that he can include which of the following Foods in his diet (select all that apply) a) Sardines b) Nuts c) Apricots d) liver e) scallops Nurse is caring for a client following a total knee arthroplasty. The client reports a pain level of 6 on a paint scale of 0 to 10. Which of the following interventions should the nurse take? a) Place pillowsl under the clients knee b) gently massage the area around the clients incision c) apply an ice pack to the clients knee d) perform range of motion exercises to the clients knee A nurse is caring for a client who has 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) Its going to be difficult to tell my parents I can't take them to their appointments anymore c) I feel bad that I have to ask my partner to keep the house clean d) These crutches will make it impossible to care for my child A nurse is assessing a client who is preoperative and reports an allergy to bananas. The nurse should recognize that the client is at risk for an allergic cross-reactivity to which of the following substances? a) adhesive tape b) Latex c) Anesthetics d) povidone iodine A nurse on a medical unit is planning care for a group of clients. Which of the following clients should the nurse attend to First? a) A client who has chronic obstructive pulmonary disease in oxygen saturation of 89% b) a client who has left-sided paralysis and slurred speech from a prior stroke c) a client who has thrombocytopenia and reports a nosebleed d) a client who has multiple sclerosis and reports Ataxia and vertigo A nurse is monitoring a client who is receiving two units packed RBC's. Which of the following manifestation indicates a hemolytic transfusion reaction? a) back pain b) Hypertension c) Chills d) bradycardia A nurse is teaching a client who has diabetes mellitus about foot care. Which of the following instruction should the nurse include? a) Use a heating pad to keep your feet warm at night b) wear loose-fitting slippers around the house c) where cotton rather than nylon socks d) wash your face twice per day with antibacterial soap and hot water A nurse is providing teaching to a client who has a deep vein thrombosis (DVT) . Which of the following findings should the nurse identify as a risk factor for the development of the DVTs? a) NSAID use b) hypertension c) oral contraceptive use d) cirrhosis 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 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 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) Furosemide d) Diphenhydramine 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 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 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 A nurse is caring for a client who weighs 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 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 hours 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 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? 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 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 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 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 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) Respiratory rate of 24 / min b) adventitious breath sounds c) weight loss of 1.8 kg (4 lb) in the past 24 hours d) elevation in blood pressure A nurse is preparing to administer furosemide to a client who has acute heart failure. Which of the following laboratory results should the nurse [Show Less]
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ATI RN MEDICAL SURGICAL PROCTORED EXAM 2019 | 100% 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 record 6. 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 mirror d) 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 [Show Less]
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ATI MEDICAL SURGICAL PROCTORED EXAMS
ATI Medical Surgical Proctored Exam Form B A nurse is caring for a client who is having a seizure. Which of the following interventions in the nurse’s ... [Show More] priority? Turn the client to the side A nurse is caring for a group of clients. The nurse should plan to make a referral to physical therapy for which of the following clients? A client who is receiving preoperative teaching for a right knew arthroplasty A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The nurse should postpone the testing and report to the provider which of the following findings? Current medications A home health nurse is assigned to a client who was recently discharged from a rehabilitation center after experiencing a right-hemispheric stroke. Which of the following neurologic deficits should the nurse expect to find when assessing the client? (SATA) Visual spatial deficits Left hemianopsia One-sided neglect A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take? Place a pillow between the client’s legs A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place which of the following items at the client’s bedside table? Suction machine A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish a ureterostomy. Which of the following statements should the nurse include in the teaching? You should cut the opening of the skin barrier one-eighth inch wider than the stoma A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit? Heart rate 110 A nurse is planning care for a client who is undergoing brachytherapy via a sealed vaginal implant to treat endometrial cancer. Which of the following actions should the nurse include in the client’s plan of care? Wear a lead apron while providing care to the client A nurse is planning to provide discharge teaching for the family of an older adult client who has hemianopsia and is at risk for falls. Which of the following instructions should the nurse include? Remind the client to scan their complete range of vision during ambulation A nurse is planning care to decrease psychosocial health issues for a client who is starting dialysis treatments for chronic kidney disease. Which of the following interventions should the nurse include in the plan? Tell the client that it is possible to return to similar previous levels of activity A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which of the following findings indicate that the client is experiencing increased intracranial pressure? (SATA) Sleepiness exhibited by the clientWidening pulse pressure Decerebrate posturing An older adult client is brought to an emergency department by a family member. Which od the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration? Urine specific gravity 1.045 A nurse is caring for client who has a prescription for enalapril. The nurse should identify which of the following findings as an adverse effect of the medication? Orthostatic hypotension A nurse in a provider’s office is caring for a client who requests sildenafil to treat erectile dysfunction. Which of the following statements should the nurse make? You will not be able to use sildenafil if you are taking nitro 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 plan of care to prevent a pseudomonas aeruginosa infection? Avoid placing plants or flowers in the clients room A nurse is teaching a class about client rights. Which of the following instructions should the nurse include? A client should sign an informed consent before receiving a placebo during a research trial A nurse is caring for a client who is receiving morphine for daily dressing changes. The client tells the nurse, “I don’t want any more morphine because I don’t want to get addicted”. Which of the following actions should the nurse take? Instruct the client on alternative therapies for pain reduction A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. Which of the following prescribed medications should the nurse instruct the client to withhold for 48hr prior to cardioversion? Dig A nurse is caring for a client 1 hr following a cardiac cath. The nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions is the nurse’s priority? Apply firm pressure to the insertion site A nurse is assessing a client who has Graves’ disease. Which of the following images should indicate to the nurse that the client has exophthalmos? A nurse is caring for a client who has a stage III pressure injury. Which of the following findings contributes to delayed wound healing? Urine output 25ml/hr A nurse is providing teaching to a client who is receiving chemo and has a new prescription for epoetin alfa. Which of the following statements indicated an understanding of the teaching? I will monitor my blood pressure while taking this medication A nurse is providing discharge instructions to a client following an upper gastrointestinal series with barium contrast. Which of the following information should the nurse provide? Increase fluid intake A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurses priority? Tachycardia A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate this risk, which of the following dietary alterations should the nurse recommend? Add cabbage to the diet A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first? Instruct the client to allow the machine to breathe for them A nurse is providing preoperative teaching for a client who is scheduled for an open cholecystectomy. Which of the following actions should the nurse take? Demonstrate ways to deep breathe and cough A nurse and an assistive personnel are caring for a client who has bacterial meningitis. The nurse should give the AP which of the following instructions? Wear a mask A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take? Remain with the client for the first 15 min of the infusion 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? I am taking this medication to increase my energy level A nurse is caring for a client who has hepatic encephalopathy that is being treating with lactulose. The client is experiencing excessive stools. Which of the following findings is an adverse effect of this medication? Hypokalemia A nurse is providing teaching to an older adult female client [Show Less]
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ATI MED SURG STUDY GUIDE 2021
Med-Surg Study Guide 2021 Heart Failure (HF) (10) S/S left HF and S/S right HF Signs & Symptoms Left sided failure (blood backing up in lun... [Show More] gs) Right sided failure (blood backing o up Venus system = edema) *Dyspnea, orthopnea (shortness of breath while *Jugular vein distention Lying down), nocturnal dyspnea *Ascending dependent edema (legs, *Fatigue ankles, sacrum) *Displaced apical pulse (hypertrophy) *Abdominal distention, ascites *S3 heart sound (gallop) *Fatigue, weakness *Pulmonary congestions (dyspnea, cough, *Nausea and anorexia Bibasilar crackles) *Polyuria at rest (nocturnal) *Frothy sputum (can be blood-tinged) *Liver enlargement (hepatomegaly) *Altered mental status and tenderness *Manifestations of organ failure, such as *Weight Gain Oliguria (decrease in urine output) Treatment o Diuretics o Ace inhibitors = Valsartan o ARB’s o CCB;s o Digoxin = strengthens heart o Beta Blockers o Vasodilators = Nitro o Warfarin, Plavix, blood thinner How to monitor HF – patient education o Daily weight o Diet = low sodium o Smoking cessation o Position: high fowlers o Monitor VS o Monitor lab work o Heart rate = below 60 do not administer digitalis = listen to apical for a full minute Nursing actions/interactions associated with monitoring HF o AROM o Fluid restriction o Low sodium diet o Weights o I & O o Medications = 2 | P a g e diuretics digitalis = increase myocardial contraction which slows conduction normal 0.5 -2 Ace inhibitors = biggest side effects = cough Dobutamine for severe heart failure Digoxin = decrease in potassium Toxic s/s = halos, vision changes, arrythmias, N/V Oxygen above 92% o Monitor labs o Administer medications Patient Education o Low sodium diet o Emotional support o Effective breathing techniques o Daily weight at same time everyday notify dr. if more than 2lbs in a day or 5lb in a week. o Report swelling of feet or ankles o Report shortness of breath o Common adverse effects of medication Key assessments with meds associated with HF o Respiratory assessment o Auscultation o Urinary output o Weight o I & O o Blood Pressure o Ascites Patient education on meds used to treat HF o Lisinopril Hypotension Increased serum potassium Worsening renal function Cough o Losartan Hypotension Increased serum potassium Worsening renal function o Hydralazine Hypotension o Metoprolol Decreased heart rate Hypotension Dizziness 3 | P a g e Fatigue o Diuretics Electrolyte imbalances Renal dysfunction Decreased BP I & O Daily weights Hypokalemia Hypernatremia o Spironolactone Hyperkalemia Hyponatremia o Digoxin Bradycardia Toxicity Hemophilia (6) Both types of hemophilia are inherited as X linked traits so mostly men are affected o Hemophilia A (factor VIII deficiency) measured by aPTT (intrinsic Pathway) o Hemophilia B (Christmas Disease, factor IX deficiency) measured by aPTT (intrinsic Pathway) Treatment o Replacement of the missing factor VIII or IX o Fresh frozen plasma o Recumbent (manmade) factor treatment o aPTT = 30 - 35 Nursing actions/interventions when caring for hemophiliac o Sign/Symptoms Lethargy Joint pain o Prevent bleeding o Safety precautions (fall precautions) o Avoid IM injections o Avoid meds that may encourage bleeding o Monitor for internal bleeding Coffee ground emesis Cola colored urine Tarry stools Patient education on living with hemophiliac o Can’t take aspirin/NSaids o Before dentist replace factors [Show Less]
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ATI MED SURG COMPREHENSIVE EXAM |100% Best paper
MED SURG COMPREHENSIVE EXAM 1. A parent whose 12-year-old child has been inhaling paint fumes asks the nurse, "Can he become addicted to paint fumes?" Wha... [Show More] t is the best response for the nurse to provide? A. Only hard drugs like cocaine and heroin can cause problems with addiction. B. Abuse of any of the inhalants can eventually lead to addiction C. Any time you use an illegal substance, you are abusing drugs. D. Tell me what you think may have caused him to start inhaling paint fumes. (C) Rationale: provides accurate information and answers the parent's question. (A) is a common misconception. (B) is not usually an effective treatment strategy, and information should be sought after determining if any other drugs have been taken. (D) does not address the parent's question. 2. A young adult female is brought to the emergency room by family members who report that she ingested a large quantity of acetaminophen (Tylenol). The nurse should prepare for which treatment to be implemented? A. IV administration of Narcan. B. Gastric lavage with normal saline. C. Acetylcysteine (Mucomyst) 140 mg/kg D. Syrup of ipecac per nasogastric tube. Mucomyst (C) is the antidote for acute acetaminophen (Tylenol) poisoning and is the treatment of choice for an overdose. (A) is used for an overdose of narcotics. (B) is used for ingestion of non-corrosive products such as iron tablets. (D) might also be implemented, depending on the amount of drugs ingested and the time elapsed since ingestion. Awarded 1.0 points out of 1.0 possible points. 3. An 8-year-old male client with nephrotic syndrome is in remission following treatment with prednisone (Deltasone). The nurse should teach the child to check his urine for which finding? A. Glucose. B. White blood cells. C. Protein D. Ketones. Children should be taught to check for protein (albumin) (0) in the urine daily, because a positive reading for protein in the urine is often the only indicator of a relapse of nephrotic syndrome. (A) is an indication of infection. (8 and C) should be assessed while the child is receiving corticosteroid therapy, since corticosteroids increase blood glucose. Awarded 1.0 points out of 1.0 possible points. 4. When making a home visit to a family with a teething 4-month-old, what information is most important for the nurse to provide the parents? A. A slight fever is often associated with teething, but a fever lasting more than three days requires medical attention. B. No action is required for the common symptoms associated with teething, which include drooling, irritability, and poor sleeping. C. Providing cooled teething toys can help decrease the discomfort associated with tooth eruption. D. Though child development is characterized by individual differences, first teeth usually erupt during the seventh month. A slight fever that persists longer than three days is likely to be associated with a pathological process, not teething, and the parents should seek the attention of their healthcare provider if it occurs (D). (A, B, and C) provide useful information about teething, but do not have the priority of (D). Awarded 1.0 points out of 1.0 possible points. 5. To treat cystitis, a 14-day course of treatment with cephalexin (Ceclor) is prescribed for a client residing in a long-term care facility. Which action is most important for the nurse to take prior to administering the first dose of this medication? A. Review the client's fasting blood glucose levels for a hyperglycemic trend. B. Restrict the use of dairy products in the client's diet for the next 3 weeks. C. Take the client's vital signs prior to the first dose and once daily for 14 days. D. determine if the client has ever had a hypersensitivity reaction to penicillins Most individuals who have an allergy to penicillins (B) are at risk of hypersensitivity to cephalosporins. To prevent a potential hypersensitivity reaction that could cause a life-threatening episode of anaphylactic shock, the nurse must determine if the client has a known penicillin allergy before giving the client a cephalexin (Ceclor) dose . (A, C, and D) are not required interventions for the administration of cephalexin (Ceclor). Awarded 1.0 points out of 1.0 possible points. 6. A staff member tells the charge nurse that a float nurse assigned to work on the unit has made several medication errors in the past, but is currently working with the education department to improve this skill. What action is best for the charge nurse to take? A. Assign the float nurse to function as a UAP for the day. B. arrange for someone to be available to assess and assist the float nurse C. Dismiss the staff nurse's report about the float nurse because it may be just gossip. D. Call the nursing supervisor and request a different employee be sent to the unit. The float nurse is receiving education, but careful assessment of her or his skills and assistance, as needed, is still warranted, so (D) is the best choice. Though the staff member's report may indeed be gossip, failure to pay attention to the information could constitute negligence on the part of the charge nurse (A). (B) is not the best way to manage the unit. (C) is not the best use of a licensed person and would also eliminate the float nurse's opportunity to improve medication administration skills. Awarded 1.0 points out of 1.0 possible points. 7. The blood pressure readings obtained by a unlicensed assistive personnel (UAP) are consistently different from those obtained by other staff members. What action should the charge nurse take first? A. Make staff members aware of the possible errors in blood pressure readings. B. observe the UAP performing blood pressure measurements C. Counsel the UAP about the inaccurate blood pressure readings. D. Ask the education department to provide additional training for the UAP. The charge nurse should first observe the UAP1s performance (B), then take appropriate action, which might include (A, C and D). Awarded 1.0 points out of 1.0 possible points. 8. A client at 13-weeks' gestation is scheduled for an amniocentesis in one week. The nurse knows that the primary reason for conducting this procedure is to obtain what information? A. Determination of gestational age. B. Level of fetal lung maturity. C. Quantification of alpha-fetoprotein levels. D. presence of genetic disorders Amniocentesis is done at 14 to 16 weeks' gestation to determine chromosomal, genetic, and metabolic disorders (B). Amniocentesis in the third trimester assesses fetal lung maturity (A) by evaluating the lecithin/sphingomyelin (US) ratio and the presence of phosphatidylglycerol (PG). Amniocentesis is performed to quantify alpha-fetoprotein levels(C) after abnormal maternal serum alpha-fetoprotein levels (done at 15 to 18 weeks) are found. While specific levels of creatinine, bilirubin, and lipid cells are present in amniotic fluid only after 35 to 36 weeks' gestation, gestational age (D) is commonly evaluated by ultrasound. Awarded 1.0 points out of 1.0 possible points. 9. A hospitalized 5-year-old boy recovering from surgery refuses to drink fluids. Which intervention is best for the nurse to implement? A. offer the child a popsicle and allow him to pick the flavor he prefers B. Make a game of seeing who can finish a glass of water first--the nurse or the child. C. Tell the child he can go outside after he drinks a full glass of water. D. Ask the parents to participate in encouraging the child's fluid intake. Fluids in popsicle form (C) are an excellent choice for a child, and small children react best when they are provided with possible choices, such as choosing a flavor. (A) is a good intervention, but (C) is better. (B) is manipulative and the nurse must be careful not to make promises that may not be possible. Although (D) may be useful, it may also be manipulative and is not as likely as (C) to obtain the ultimate goal of increasing fluids. Awarded 1.0 points out of 1.0 possible points. 10. An overweight adolescent girl has been to the school nurse three times in the last two months complaining of vaginal and urinary tract infections. What action should the nurse take first? A. Encourage the girl to see the school counselor. B. Counsel the girl regarding hygiene. C. ask if she is going to the bathroom frequently D. Teach the girl the importance of practicing safe sex. All actions might be implemented, depending on further assessment findings. However, based on the data presented, the nurse should ask questions directed toward symptoms of diabetes (B). Recurrent vaginal and urinary tract infections are often an early sign of IDDM. (A, C, and D) require further assessment data to support their implementation. Awarded 1.0 points out of 1.0 possible points. 11. About mid-morning, a 10-year-old child reports to the school nurse complaining of nausea, dizziness, and chills. Further assessment reveals that this child is sweating profusely and has a blood glucose level of 57 mg/di. Based on these assessment findings, which food is best for the nurse to encourage the child to eat? A. A piece of bubble gum. 8. A soft drink. C. A chocolate bar. D. peanut butter crackers Peanut butter crackers (C) provide a complex carbohydrate, plus protein and fat. This child is exhibiting signs and symptoms of mild to moderate hypoglycemia and needs to eat about 15 grams of carbohydrates to increase the blood sugar level. Complex carbohydrates are broken down more slowly and are slower acting than simple sugars, so they prevent the blood glucose level from peaking and then dropping precipitously. (A, 8, and D) contain only simple sugars. Awarded 1.0 points out of 1.0 possible points. 12. When examining the wound of a client who had abdominal surgery yesterday, the nurse finds that the wound edges are close together, there is no sign of redness, and there is a slight amount of bright red blood oozing from the incision. What action should the nurse take? A. Increase the IV fluid rate and encourage the client to eat more ice chips. B. Notify the healthcare provider that the client's wound is producing a sanguineous drainage. C. record these findings in the clients record D. Observe closely for possible dehiscence. These are normal findings for one-day postoperative and indicate that the wound is healing by primary intention (A). Dehiscence (8) is separation of a surgical incision, and there is no indication that this is a possibility at this time. Serosanguineous drainage is thin and red and is composed of serum and blood, and this client is not exhibiting this finding, and even if the wound was producing this drainage, the finding does not warrant (C). There is no indication of dehydration, so (D) is not indicated at this time. Awarded 1.0 points out of 1.0 possible points. 13. When culturing a wound, the nurse should obtain the sample from which part of the wound? A. Any particularly painful area of the wound. B. The outer edges of the wound. C. areas containing purulent and pooled exudates D. All necrotic sections of the wound. To collect a wound culture, the nurse should first clean the wound to remove skin flora and then insert a sterile swab from a culturette tube into the wound secretions (C), then return the swab to the culturette tube, cap the tube, and crush the inner ampoule so that the medium for the organism growth coats the swab. The culture should not be collected from (A, B, or D). Awarded 1.0 points out of 1.0 possible points. 14. The nurse administers dopamine (lntropin) IV infusion at 3 mcg/kg/min to a critically ill, hypotensive client. What is the intended effect of this treatment? To increase A. urine output to 55 mL/hr. Correct B. pulse to 132 beats/min. C. blood pressure to 140/80. D. respirations to 24 breaths/min. The expected outcome of this treatment is an increase in urine output due to increased renal perfusion (B). Dopamine, a catecholamine, provides renal and mesenteric vasodilation at a low dosage level, such as the 3 mcg/kg/minute infusion that was prescribed for this client. A higher dose of dopamine is needed to affect (A or C) to the levels indicated in a critically ill client who is hypotensive. (D)'s effect would be minimal. Awarded 1.0 points out of 1.0 possible points. 15. Yesterday a female client who is delusional told the nurse that her healthcare provider needs to be released from her case because they are going to get married on her birthday. Which statement made by the client today indicates that the client is less delusional? A. I think I should talk about this in group. B. I really wish that my birthday wasn't so soon. C. I don't talk about things like that anymore. Correct D. The doctor won't talk with me about this. When the client states that she doesn't want to talk about things like that anymore (B), she is likely less delusional, because when a client begins to question the delusional belief or stops talking about it, the client is becoming less delusional. (A, C and D) lack evidence that the client no longer maintains the delusion. Awarded 1.0 points out of 1.0 possible points. 16. A newborn is brought to the admissions nursery by the nurse and the father of the baby. The baby weighs 9 pounds 3 ounces and measures 21 inches head to toe. Which description is a correct assessment of this infant? A. Macrosomia with an average length. B. above average in weight but average in length C. Above average in weight but below average in length. D. Above average in weight and length. The baby is definitely above the average weight of 7 1/2 pounds. The average newborn length ranges from 18 to 21 inches, so the baby is in the upper limit of average length (A). (Band C) are both incorrect. (D) is a term used to describe neonates of poorly controlled diabetic mothers and refers to a large body size and birth weight of 4000 g or more. Since this infant is above average in weight but is high average in length, he is most likely a normal, large infant. Determining how large the parents are provides additional worthwhile assessment data. Awarded 1.0 points out of 1.0 possible points. 17. A client has a precipitous delivery attended only by the nurse. What nursing intervention has the highest priority? A. Clamp and cut the umbilical cord. B. Massage the uterine fundus until it is firm. C. ensure an adequate airway in the newborn D. Assess for signs of placental detachment. Ensuring an adequate airway in the newborn (A} is the priority. (B, C and D) can be delayed until this is accomplished. Awarded 1.0 points out of 1.0 possible points. 18. A new mother asks the nurse why her infant son has yellow liquid coming out of his eyes. Which explanation is correct? A. Conjunctivitis neonatorum is common in newborns. B. Most infants have drainage from their eyes which usually resolves within 2 to 3 days of life. C. An antibiotic ointment is placed in each newborn's eyes to prevent infection D. This type of question should be discussed with your pediatrician. Antibiotic ointments, such as erythromycin ointment, are placed in the lower conjunctiva of each eye to prevent chlamydia and gonorrhea (A). (B) is not a common finding in newborns. (C) is dismissing the mother's questions and may alarm the family because the nurse appears unwilling to discuss the condition. An infant may have yellow drainage related to administration of an antibiotic ointment, but it should be resolved as soon as the infant is bathed (D). Awarded 1.0 points out of 1.0 possible points. 19. A client with severe preeclampsia is receiving magnesium sulfate 2 grams IV hourly. The nurse assesses the client and finds: blood pressure 140/90, pulse 100, respirations 10, deep tendon reflexes 1+, and urinary output 130 mL in 4 hours. The nurse will discontinue the magnesium infusion based on which assessment finding? A. Blood pressure of 140/90. B. Deep tendon reflexes 1+. C. respirations of 10 Correct D. Urinary output of 130 ml in 4 hours. With respirations less than 12 (C), the client is at risk for developing respiratory arrest and the magnesium sulfate should be discontinued. Other cardinal signs of magnesium toxicity include urinary output Awarded 1.0 points out of 1.0 possible points. 20. A male client, who has a 3-year history of Type 2 diabetes that is controlled by diet, is being discharged postmyocardial infarction with a prescription of nitroglycerin tablets for chest pain and regular insulin for treatment of his diabetes. Following teaching, the client tells the nurse that he will make sure he keeps his nitroglycerin bottle in his pants pocket at all times, that he eats and drinks a snack before going to bed, and that he checks his blood glucose before eating in the morning. This client requires further teaching on which subject? A. Fluid intake. B. Diabetic diet. C. storing nitroglycerin Correct D. Blood glucose monitoring. Nitroglycerin must be kept in the original dark-tinted, glass, screw-top bottle so that contact with air can be avoided, and keeping it in a pants pocket exposes it to body heat (A), which can reduce its effectiveness. The client should keep the medication in a jacket pocket, which would reduce direct body contact with the bottle. He should also check the expiration date on the bottle (it is good for 3 months and tingling in the mouth indicates that the drug is fresh). Some people experience a headache when taking nitroglycerin, due to the vasodilatation effect. The client's habits regarding (B, C, and D) indicate that he understood the teaching, so no further teaching is required. Awarded 1.0 points out of 1.0 possible points. 21. A client who had a cesarean section two weeks ago is admitted to the hospital for an infected surgical abdominal wound. Which room is best for the nurse to assign this client? A. A private room on a medical unit. Correct B. A postpartum room in the birthing center. C. A semi-private room on a surgical unit. D. A negative pressure room. To protect others from contamination, the nurse should assign this client to a private room (0). (A) is an isolation room used for clients with TB. (B) should not be assigned because of the possibility of cross-contamination by the infected client. (C) should not be assigned because the 08 unit is considered 11clean. 11 Awarded 1.0 points out of 1.0 possible points. 22. A client with acute pancreatitis is admitted to the medical unit. During the nurse's admission interview, which assessment has the highest priority? A. Intensity of pain. Correct B. History of alcohol intake. C. Frequency of vomiting. D. Time of last meal. The hallmark sign of pancreatitis is severe abdominal pain (D), due to autodigestion of the pancreas by the enzymes amylase and lipase. (A, B, and C) are also important but are of less priority then (D). Awarded 1.0 points out of 1.0 possible points. 23. Which outcome is best for the nurse to include in the plan of care for a client with impaired social interaction and obsessive-compulsive disorder? A. Participates in one social or recreational activity each morning and afternoon. Correct B . Avoids obsessive verbalizations while interacting with family and staff. C. Describes success in dismissing persistent thoughts that used be bothersome. D. Reports that the obsessions and compulsions experienced are silly. Participation in social/recreational activities (D) is an expected outcome of treatment for a client with impaired social interaction because it indicates that the client is no longer totally immersed in obsessive thoughts and compulsive rituals. (A and C) are outcomes related to disturbed thought processes, rather than social interaction. (B) does not suggest progress since many clients have this understanding but are powerless to change their behavior. Awarded 1.0 points out of 1.0 possible points. 24. While conducting a routine health assessment of a woman who recently immigrated to the U.S. from China, the nurse notes that the client makes little direct eye contact, is deferential to healthcare personnel, and avoids sharing her personal thoughts and feelings. What action should the nurse take? A. Determine if there is a family history of emotional disorders. B. Refer the client to a psychiatric outpatient clinic. C. Encourage the woman to attend citizenship classes. D. Continue the interview process and record the findings Correct The nurse should accept these behaviors as culturally determined and continue with the interview (A). These behaviors are common in the Chinese culture where people are members of strong, cohesive groups that focus on the group rather than the individual. These behaviors are not related to a psychiatric disorder (Band C). Citizenship (D) is an individual choice, while cultural behaviors evolve over time. Awarded 1.0 points out of 1.0 possible points. 25. After the sudden death of a severely injured client while in transport by helicopter, the flight nurse discovers that the oxygen tank that was attached to the oxygen supply was empty during the transport. What action should the flight nurse take? A. Complete an adverse occurrence report and submit it to the nurse-manager Correct B . Advise the flight crew of the situation, then suggest that no further discussion be held. C. Send an anonymous letter explaining the situation to the family of the client. D. Replace the empty tank without reporting the situation to any members of the agency. A medication error occurred, so an adverse occurrence report should be completed and submitted to the nurse-manager (B) for evaluation of the situation, so that measures can be implemented to prevent a repeat of the occurrence. (A, C, and D) do not allow for review of the system to prevent a repeat of the occurrence. Awarded 1.0 points out of 1.0 possible points. 26. A client has a living will and an advance directive specifying no intubation or CPR. The client's spouse and children tell the nurse privately that they want the client resuscitated, if the need arises. How should the nurse respond? A. Every effort must be made to honor the family's wishes about their loved one. B. Notify the healthcare provider of the family's wishes, so a decision can be made. C. Nurses use their best judgment based on the client's condition. D. The healthcare team must honor the written wishes of the client Correct The client () should be the ultimate decision-maker regarding treatment or refusal of treatment. The client's ethical right to autonomy and legal right to give informed consent for treatment are recognized in both legally created special directives and living wills. Although family members are very important in the care and support of the client, the nurse (), and healthcare provider () must respect the legal document that the client created to direct the course of treatment (). Awarded 1.0 points out of 1.0 possible points. 27. The charge nurse observes that a demographic screen has been left open on a hallway computer by a nurse who is responding to a call light because the unlicensed assistive personnel (UAP) is involved in a personal phone call. Which action should the charge nurse take first? A. Instruct the UAP to end the phone call immediately. B. Page the unit manager to address the situation. C. Send a UAP into the client's room to relieve the nurse. D. Close the demographic screen on the computer Correct The greatest priority is for the charge nurse to close the computer screen (), because health information stored in computerized systems is considered to be Protected Health Information (PHI) under HIPAA (Health Insurance Portability and Accountability Act). (others) may be indicated, but are of less priority than (d). Awarded 1.0 points out of 1.0 possible points 28. A high school senior is complaining of a persistent cough and admits to smoking 10 to 15 cigarettes daily for the past year. He is convinced that he is hopelessly addicted to tobacco since he tried unsuccessfully to quit smoking last week. Which intervention is best for the nurse to implement? A. Provide the student with the latest research data describing the long-term effects of tobacco use. B. Encourage the student to associate with non-smokers only while attempting to stop smoking C. Describe cigarette smoking as a habit that requires a strong will to overcome its addictiveness. D. Tell the student that he is still young and should continue to try various smoking cessation methods. It is difficult to cease smoking when surrounded by those who smoke, and adolescents are particularly influenced by peers, so (A) is the most important intervention for the nurse to implement. (B) is not likely to be helpful and offers no concrete suggestions for smoking cessation. (C) is condescending. Risks associated with smoking must already be known to this adolescent who is already attempting to stop the habit (D). Awarded 1.0 points out of 1.0 possible points. 29. Which client data is most important for the nurse to obtain prior to beginning a client's blood transfusion of packed redblood cells? A. Weight. B. Oxygen saturation. C. Vital signs. D. Skin turgor. Baseline vital signs (D) are essential to obtain prior to administering a blood transfusion, so that vital signs measured during the transfusion administration can be compared to the baseline to assess for the onset of a transfusion reaction. (A, B, and C) provide less significant data immediately prior to the administration ofthe transfusion. Awarded 1.0 points out of 1.0 possible points. 30. A healthcare provider tells the nurse that a certain medication will be prescribed for a client. After the prescription is written, the nurse notes that the provider has prescribed another medication that sounds similar to the medication that the provider and nurse originally discussed. What action should the nurse implement? A. Write the correct prescription as a verbal order received from the healthcare provider. B. Contact the healthcare provider to clarify the prescription intended for the client. Correct C. Consult with the pharmacist to determine the best medication for the client. D. Correct the misspelled medication in the written prescription and initial the change. Since the nurse received contradictory information, the provider should be contacted (D) to clarify the intended prescription. (A) may result in a medication error. The nurse does not have the authority to alter prescriptions (8). The pharmacist (C) cannot determine the best medication for a client. Awarded 1.0 points out of 1.0 possible points. 31. Which action should the nurse take first when performing tracheostomy care? A. Oxygenate with 100% oxygen B. Cleanse around the stoma. C. Secure the new neckstrap. D. Suction the tracheostomy. Hyperinflation with 100% oxygen (C) helps minimize hypoxia and atelectasis during the suctioning procedure, so the nurse should take this action first, before (A, 8, or D). Awarded 1.0 points out of 1.0 possible points. 32. Current assessment findings for a client who is withdrawing from barbiturates are: blood pressure 135/90, temperature 97.6° F, pulse rate of 98 beats/minute, and respiratory rate 22 breaths/minute. The client is also experiencing insomnia, restlessness, confusion, and pronounced muscle twitching. What action should the nurse take? A. Place the client in a vest-type restraining jacket. B. Assess vital signs q15 minutes until stable. C. notify the healthcare provider of the clients status Correct D. Encourage the client to take a warm bath to help relax. The healthcare provider should be notified (A) so that medications can be prescribed to prevent seizures. Grand mal seizures sometimes occur during barbiturate withdrawal, and pronounced muscle twitching can herald seizure activity. (B) does not prevent seizures. (C) is not indicated simply because the client is confused and restless. (D) does not treat these symptoms. Awarded 1.0 points out of 1.0 possible points. 33. When preparing to insert an indwelling urinary catheter, the nurse applies sterile gloves and then tests the catheter balloon for patency. What action should the nurse implement next? A. Place a sterile drape under the client's buttocks. B. Apply a sterile lubricant to the end of the catheter C. Discard the gloves and apply new sterile gloves. D. Instruct the client to inhale and then exhale slowly. After testing the balloon for patency, the nurse should next lubricate the end of the catheter (D). The sterile drape should already be positioned under the client's buttocks (A). The client is instructed in breathing (B) just prior to insertion, not at this point in the procedure, since the nurse has not yet cleansed the meatus. New sterile gloves are not necessary (C) unless the nurse contaminates the original gloves. Awarded 1.0 points out of 1.0 possible points. 34. Which biological practices are federally regulated for healthcare workers? (Select all that apply.) A. As Low as Reasonably Allowable standard (ALARA). B. N-95 tuberculosis standard C. Resource Conservation and Recovery Act (RCRA). D. Standard precautions E. Blood-borne pathogen standard F. Biological product exposure limit (BPEL). Correct responses are (A, B, C, and E). Basic standards for healthcare workers, as delineated by Occupational Safety and Health Administration (OSHA), include standard precautions (A), droplet precautions using N-95 respiratory particulate masks (B) when caring for a client who is positive for tuberculosis, and required annual updates for healthcare workers about blood-borne pathogen transmission (C), methods of minimizing exposure, and employee rights. (E) requires labeling, storage, transportation, and disposal of biological waste according to federal standards. (F) is an occupational health concept implemented to minimize employee and environmental exposures and may not be consistent with an OSHA recommendation. (D) is not an applicable mandate. Awarded 1.0 points out of 1.0 possible points. 35. Which contextual factors are considered external environmental influences in the framework for occupational health programs and services? (Select all that apply.) A. Socio-economic status. B. Workforce. C. Legislation/regulation. Correct D. Interventions. E. Technology. Correct F. Economics Correct Correct selections are (A, C, and F). (A) affects the health of the company and its workforce productivity, in terms of profitability, growth, and expansion. (C) adds to an industry's capacity to develop and implement new or improved work processes. (F) in the workplace, such as the blood- borne pathogen standard, affects the workforce in terms of requirements, administration, and control strategies. Occupational safety programs are built around the workforce (B) to strive for maximum internal productivity. (D) are internal environmental influences of an occupational health and safety program. (E) is a demographic variable commonly used in epidemiology. Awarded 1.0 points out of 1.0 possible points. 36. Which client requires the most immediate intervention by the nurse? A. A client with low back pain who is experiencing tolerance to the effects of an analgesic. B. An adolescent with a history of drug addiction who is requesting a sedative. C. a young adult who is reporting an anaphylactic response to an antibiotic Correct D. A client with a chronic renal disease who is demonstrating a therapeutic response to a diuretic. An anaphylactic response (D) is a severe allergic reaction that may result in airway constriction and shock, so the nurse should first respond to this potentially life-threatening situation. Drug tolerance (A) occurs when there is a decreased physiological response after repeated administration of a drug, so the client may be experiencing pain, but this is of less priority than (D). Possible drug-seeking behaviors (B) and diuresis, the therapeutic response to a diuretic (C), require intervention by the nurse but are of less priority than (D). Awarded 1.0 points out of 1.0 possible points. 37. A nurse is caring for a male client with paranoid schizophrenia who believes that his antipsychotic medications are poison. Which intervention is best for the nurse to implement? A. Offer the medication in a concentrated form. B. Approach the client with the medication 30 minutes later C. Discard the medication and document the client's refusal. D. Describe the needfor consistently taking medications. Delusions of persecution and fear of being controlled by others are characteristic of those with paranoid schizophrenia, but these feelings fluctuate, and in 30 minutes the client may be willing to take the medications (D). (A) is an attempt to manipulate the client. (B) is unlikely to be successful based on the client's current delusions. If the client still refuses the medication after a second attempt, (C) should be implemented. Awarded 1.0 points out of 1.0 possible points. 38. Which action should the nurse implement when implementing a physical assessment of an older client? A. Speak loudly and slowly when telling the client how to assist. B. Avoid unnecessary touching while interacting with the client. C. Apply additional pressure to palpate the [Show Less]
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ATI MEDICAL SURGICAL EXAM - RESPIRATORY EXAM (ATI Med Surg Respiratory)
ATI MED SURG RESPIRATORY 1- A nurse is reviewing the discharge instruction for a client who is recovering from pneumonia. Which of the following statemen... [Show More] ts should the nurse make? -“You should avoid crowed areas.” 2- A nurse in an emergency department is assessing a client who has a flail chest from blunt chest trauma. Which of the following findings should the nurse expect: (SATA) -Cyanosis -Dyspnea -Paradoxical chest movement 3- A nurse is caring for an adolescent with cystic fibrosis. Which finding requires immediate intervention when caring for this client? -Chest pain with dyspnea Rational: chest pain and dyspnea are signs of pneumothorax and should be treated immediately. 4- A nurse in the emergency department is assessing a client admitted to the emergency department who has sustained crushing chest injuries in a car accident. Which of the following signs indicate a possible pneumothorax? -Diminished or absent breath sounds on the affected side 5- A client who had extensive pelvic surgery 24 hr ago becomes cyanotic, is gasping for breath, and complains of right-sided chest pain. What should the nurse do first? -Administer oxygen using a face mask 6- A client is admitted with second degree burns on face, neck, anterior chest, and hands. The nurse’s priority action would be: -Assess for dyspnea and stridor 7- A client who underwent a left lower lobectomy is forty-eight hrs post op. The client is receiving morphine sulfate via a patient-controlled analgesia (PCA) system and report having pain in the left thorax that worsens coughing. The nurse should: -Obtain a more detailed assessment of the client’s pain using a pain scale. 8- A nurse is caring for a client who is undergoing tracheostomy. The nurse understands that which of the following is a complication of this procedure? -Damage to the recurrent laryngeal nerve. 9- A nurse is assessing a client’s arterial blood results. The results are pH 7.50, bicarbonate 32mEq/L, and PaCO2 36 mmHg. Which of the following do these arterial gas results indicate? -Metabolic alkalosis 10- A nurse is caring for a client on a ventilator who has ventilator settings with a preset tidal volume. Which best describes the tidal volume (VT) in this setting: -The amount of air inhaled with each breath 11- The nurse is caring for a client who has just been intubated for respiratory failure. The physician orders the ventilator to be set SIMV mode. Which best describes SIMV? -A preset number of breaths delivered to the client at certain volume 12- A client with asthma is scheduled for treatment with methylxanthine for nocturnal wheezing. Which of the following drugs are methylxanthine drugs that are appropriate for the treatment of this client? (SATA) -Theophylline -Aminophylline 13- The nurse is administering cromolyn sodium (Intal) for client with asthma. Which of the following are true about this drug? (SATA) -It causes headache -It prevents an attack 14- A nurse caring for a client with hemothorax. The physician plans to insert a right-sided chest tube. (La pregunta pide ordenar los cuadritos en el orden correcto) -Check the physician order and gather the chest tube supplies -Assist the client to the correct position for placement. -Assist the provider with the chest tube insertion -Move the drainage system unit so that it is below the level of the chest -Administer pain medication as required -Encourage the client to cough and deep breathe. 15- A 33-year-old client is in the ICU for treatment of acute respiratory distress syndrome (ARDS). (la pregunta pide ordenar los pasos para realizar endotraqueal suctioning en orden) -Turn on the suction to 80-120 mmHg -Pre-oxygenate the client by providing 100% oxygen through the ET tube -Insert the suction catheter into the ET tube until resistance is met, taking care not to apply suction with insertion. -Apply suction while withdrawing the catheter from the ET tube -Suction the in-line catheter with saline to clear for next use. 16- The nurse is assessing a client with ARDS (acute respiratory distress syndrome). Which of the following may have caused the client’s condition? (SATA) - Heroin - Pancreatitis - Burns - Fat emboli 17- The nurse is assessing a client with extrapulmonary tuberculosis. Which of the following is true about this type of condition? (SATA) -Genitourinary system is affected -Osteomyelitis occurs 18- Which of the following devices is most appropriate for delivering a predicted oxygen concentration in a client with unstable chronic obstructive pulmonary disease (COPD)? -Venturi mask Rational: this mas allowing delivery of fixed FiO2 that depends on the flow rate and size of the entrainment port. It can delivery oxygen concentration ranging from 24-60 % and flow rates between 4-12 L/min. Used to titrate the oxygen concentration in clients with unstable COPD. 19- A nurse is assessing a client with emphysema. Which assessment findings does the nurse anticipate in this form of COPD? (SATA) -Hyperresonance on percussion of the lung area -Increased respiratory effort -Increased chest diameter when measured anteriorly and posteriorly 20- A nurse is caring for 4 new clients. When receiving reports, the nurse should prioritize assessment of which of the following? -A 70-year-old client after knee replacement complaining of sudden-onset dyspnea accompanied by chest pain 21- A charge nurse is admitting an elderly client with influenza. Which of the following precautions are necessary for preventing the transmission of influenza virus to other clients? (SATA) -The client should wear a face mas when leaving the room -The client should be assigned to a private room -Visitor contact with the client should be limited 22- A nurse is caring for a client with a tracheostomy who is conscious and beginning to advance his oral intake. Which of the following actions should the nurse perform to reduce the risk of aspiration? (SATA) -Deflate the cuff before feeding -Ask the client to sit upright during feeding. With the chin in flexion 23- When providing instruction to a client newly diagnosed with asthma concerning the correct use of a corticosteroid inhaler and short-acting beta agonist inhaler (albuterol), which of the following should the nurse relay? -“ Use the albuterol inhaler first for symptomatic treatment” 24- A nurse is caring for a client with measles. Which of the following strategies the nurse implements to prevent the spread of infection? -Negative-pressure room -Use of N95 respirator mask - Use of goggles and a face shield if there is likelihood of splashing of bodily secretions during an intervention [Show Less]
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ATI MED SURG EXAM 2019
ATI Med-Surg Proctored Exam A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of 7/min. The arteria... [Show More] l 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 1) Metabolic acidosis 2) Respiratory acidosis 3) Metabolic alkalosis 4) Respiratory alkalosis A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The nurse should recognize that which of the following statements by the client indicates a need for further teaching? 1) "I will avoid crossing my legs at the knees." 2) "I will use a thermometer to check the temperature of my bath water." 3) "I will not go barefoot." 4) "I will wear stockings with elastic tops." A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease. The client becomes agitated and combative when the nurse approaches him. Which of the following actions should the nurse plan to take? 1) Turn the water on and ask the client to test the temperature. 2) Obtain assistance to place mitten restraints on the client. 3) Firmly tell the client that good hygiene is important. 4) Calmly ask the client if he would like to listen to some music. A nurse is collecting data on a client’s wound. The nurse observes that the wound surface is covered with soft, red tissue that bleeds easily. The nurse should recognize this is a manifestation of which of the following? 1) Decreased perfusion 2) Infection 3) Granulation tissue 4) An inflammatory response A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm3. Which of the following food items brought by the family should the nurse prohibit from being given to the client? 1) Baked chicken 2) Bagels 3) A factory-sealed box of chocolates 4) 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? 1) Perform the client's personal care activities for her. 2) Limit the client’s fluid intake. 3) Monitor the Homan’s sign. 4) Maintain abduction of the right hip. A nurse is caring for a client who has heart failure and respiratory arrest. Which of the following actions should the nurse take first? 1) Establish IV access. 2) Feel for a carotid pulse. 3) Establish an open airway. 4) Auscultate for breath sounds. A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longer certain he wants to have the procedure. Which of the following responses should the nurse make? 1) "Why have you changed your mind about the surgery?" 2) "Bypass surgery must be very frightening for you." 3) "Your provider would not have scheduled the surgery unless you needed it." 4) "I will call your doctor and have him discuss your surgery with you." A nurse is caring for a client who is postoperative following foot surgery and is not to bear weight on the operative foot. The nurse enters the room to discover the client hopped on one foot to the bathroom, using an IV pole for support. Which of the following actions should the nurse take? 1) Walk the client back to bed immediately and get the client a bedpan. 2) Tell the client to remain in the bathroom after toileting and obtain a wheelchair. 3) Warn the client she might have to be restrained if she gets up without assistance. 4) Keep the bathroom door open to ensure the client is okay. A nurse is assisting with the care of a client who is postoperative and has a closed- wound drainage system in place. Which of the following actions should the nurse take? 1) Fully recollapse the reservoir after emptying it. 2) Empty the reservoir once per day. 3) Replace the drainage plug after releasing hand pressure on the device. 4) Irrigate the tubing with sterile normal saline solution at least once every 8 hr. A nurse is reinforcing discharge instructions with a client who has hepatitis A. Which of the following statements by the client indicates an understanding of the teaching? 1) "I will not eat fried foods." 2) "I will abstain from sexual intercourse." 3) "I will refrain from international travel." 4) "I will not order a salad in a restaurant." A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching? 1) Rest in a supine position. 2) Consume a low-protein diet. 3) Breathe in through her nose and out through pursed lips. 4) Limit fluid intake throughout the day. A nurse is caring for a client who is postoperative and has a history Addison's disease. For which of the following manifestations should the nurse monitor? 1) Hypernatremia 2) Hypotension 3) Bradycardia 4) Hypokalemia A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is to take hydroxyzine preoperatively. Which of the following effects of the medication should the nurse include in the teaching? (Select all that apply.) 1) Decreasing anxiety 2) Controlling emesis 3) Relaxing skeletal muscles 4) Preventing surgical site infections 5) 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? 1) Vitamin D 2) Vitamin A 3) Iron 4) Niacin A nurse is caring for a client after a radical neck dissection. To which of the following should the nurse give priority in the immediate postoperative period? 1) Malnourishment related to NPO status and dysphagia 2) Impaired verbal communication related to the tracheostomy 3) High risk for infection related to surgical incisions 4) Ineffective airway clearance related to thick, copious secretions A nurse is contributing to the plan of care for a client who has a spinal cord injury at level C8 who is admitted for comprehensive rehabilitation. Which of the following long-term goals is appropriate with regard to the client's mobility? 1) Walk with leg braces and crutches. 2) Drive an electric wheelchair with a hand-control device. 3) Drive an electric wheelchair equipped with a chin-control device. 4) Propel a wheelchair equipped with knobs on the wheels. A nurse is reinforcing health teaching about skin cancer with a group of clients. Which of the following risk factors should the nurse identify as the leading cause of non-melanoma skin cancer? 1) Exposure to environmental pollutants 2) Sun exposure. 3) History of viral illness 4) Scars from a severe burn : Based on a client's recent history, a nurse suspects that a client is beginning menopause. Which of the following questions should the nurse ask the client to help confirm the client is experiencing manifestations of menopause? 1) "Do you sleep well at night?" 2) "Have you been experiencing chills?" 3) "Have you experienced increased hair growth?" 4) "When did you begin your menses?" A nurse is reinforcing teaching with a client about cancer prevention and plans to address the importance of foods high in antioxidants [Show Less]
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ATI Med Surg Proctored Exam
ATI Med-Surg Proctored Exam A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instruction... [Show More] s 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. 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 client's vital signs. 4) Inform the client about the need to return to surgery. 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 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. 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. 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 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. 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 A [Show Less]
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ATI MED SURG EXAM REVIEW
ATI Med-Surg (Multiple Response) 1. A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (S... [Show More] elect all that apply.) 1) Dyspnea 2) Barrel chest 3) Clubbing of the fingers 4) Shallow respirations INCORRECT 5) Bradycardia Answer Rationale: Dyspnea is correct. Dyspnea is experienced by clients who have emphysema due to inadequate oxygen exchange in the lungs. Barrel chest is correct. The lungs of clients who have emphysema lose their elasticity, and the diaphragm becomes permanently flattened by overdistention of the lungs. The muscles of the rib cage also become rigid, and the ribs flare outward. This produces the barrel chest typical of emphysema clients. Clubbing of the fingers is correct. Air is trapped in the lungs due to their lack of elasticity, which decreases oxygenation. Clubbing results from these chronic low blood-oxygen levels. Shallow respirations is correct. Clients who have emphysema lose lung elasticity; consequently, respirations become increasingly shallow and more rapid. Bradycardia is incorrect. The heart rate will increase as the heart tries to compensate for less oxygen being delivered to the tissues. 2. 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 INCORRECT 4) Tremors INCORRECT 5) Obese extremities Answer Rationale: Buffalo hump is correct. Cushing's syndrome is a disease caused by an increased production of cortisol or by excessive use of corticosteroids. Buffalo hump, a collection of fat between the shoulders, is a common manifestation of Cushing's syndrome.Purple striations is correct. Purple striations on the skin of the abdomen, thighs, and breasts are a common manifestation of Cushing's syndrome. This is due to the collection of body fat in these areas.Moon face is correct. Moon face is a common manifestation of Cushing's syndrome. Clients who have this manifestation present with a round, red, full face.Tremors is incorrect. Tremors are not a common finding of Cushing's syndrome.Obese extremities is incorrect. Clients who have Cushing's syndrome have truncal obesity, a protuberant abdomen, with thin extremities, which is due to an alteration in protein metabolism. 3. 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. INCORRECT 3) Insert a urinary catheter. INCORRECT 4) Elevate the client’s head of bed. INCORRECT 5) Apply a cervical collar to the client. Answer Rationale: Encourage fluid intake is correct. The nurse should encourage fluids, unless contraindicated, to replace the cerebrospinal fluid that was removed during the procedure and reduce the risk for a headache. Monitor the puncture site for a hematoma is correct. The nurse should monitor and report a hematoma at the insertion site because this can indicate bleeding. Insert a urinary catheter is incorrect. There is no indication for a urinary catheter insertion. Elevate the client’s head of bed is incorrect. The client should remain flat in bed for 1 hr or more to reduce the risk for a headache. Apply a cervical collar to the client is incorrect. There is no indication for a cervical collar for this client. 4. A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is to take hydroxyzine preoperatively. Which of the following effects of the medication should the nurse include in the teaching? (Select all that apply.) 1) Decreasing anxiety 2) Controlling emesis INCORRECT 3) Relaxing skeletal muscles INCORRECT 4) Preventing surgical site infections 5) Reducing the amount of narcotics needed for pain relief Answer Rationale: Decreasing anxiety is correct. The nurse should include that hydroxyzine is an effective antianxiety agent and is used to decrease anxiety in surgical clients as well as in persons with moderate anxiety. Controlling emesis is correct. The nurse should include that hydroxyzine is an effective antiemetic and is used to control nausea and vomiting in pre- and postoperative clients. Relaxing skeletal muscles is incorrect. The nurse should recognize benzodiazepines, such as diazepam (Valium), are used to produce skeletal muscle relaxation. Preventing surgical site infections is incorrect. The nurse should instruct the client that antibiotics administered prior to surgery are used to diminish the risk of surgical site infections; hydroxyzine, an antiemetic, does not have any effect on bacteria. Reducing the amount of narcotics needed for pain relief is correct. Hydroxyzine increases the effects of narcotic pain medications. The nurse should instruct the client that when it is used for surgical clients, narcotic requirements may be significantly reduced. 5. 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.) INCORRECT 1) Polyuria 2) Blurry vision 3) Tachycardia INCORRECT 4) Polydipsia 5) Sweating Answer Rationale: Polyuria is incorrect. Hyperglycemia causes polyuria. Blurry vision is correct. Manifestations of hypoglycemia include blurry vision, tremors, anxiety, irritability, headache, and hypotension. Tachycardia is correct. Manifestations of hypoglycemia include tachycardia, tremors, anxiety, irritability, headache, and hypotension. Polydipsia is incorrect. Hyperglycemia causes polydipsia. Sweating is correct. Manifestations of hypoglycemia include sweating, tremors, anxiety, irritability, headache, and hypotension. 6. A nurse is collecting data from a client who has an exacerbation of gout. Which of the following findings should the nurse expect? (Select all that apply.) 1) Edema 2) Erythema 3) Tophi 4) Tight skin INCORRECT 5) Symmetrical joint pain Answer Rationale: Edema is correct. Swelling over the affected joints is a classic manifestation of gout. Erythema is correct. Redness over the affected joints is a classic manifestation of gout. Tophi is correct. Tophi are a classic manifestation of gout. They are nodules that form in subcutaneous tissue due to the accumulation of urate crystals. Tight skin is correct. Tight skin over the affected joints is a classic manifestation of gout. Symmetrical joint pain is incorrect. Symmetrical joint pain is a manifestation of rheumatoid arthritis, not gout. 7. A nurse is assisting in the plan of care for a client who had surgery for a bowel obstruction. The client has a nasogastric tube in place. Which of the following actions should the nurse include in the client's plan of care? (Select all that apply.) 1) Perform leg exercises every 2 hr. 2) Encourage hourly use of an incentive spirometer while awake. 3) Document the color, consistency, and amount of nasogastric drainage. INCORRECT 4) Irrigate the nasogastric tube every 4 to 8 hr. INCORRECT 5) Maintain bed rest for 48 hr following surgery. Answer Rationale: Perform leg exercises every 2 hr is correct. Postoperative clients should frequently perform leg exercises, independently or with assistance, to prevent skin breakdown.Encourage hourly use of an incentive spirometer while awake is correct. Postoperative clients should be encouraged to use the incentive spirometer ten times each hour while awake to prevent atelectasis.Document the color, consistency, and amount of nasogastric drainage is correct. Documenting the color, consistency, and amount of nasogastric drainage is appropriate to include in the client's plan of care.Irrigate the nasogastric tube every 4 to 8 hr is incorrect. Following abdominal surgery, the NG tube should not be moved or irrigated unless prescribed by the provider.Maintain bed rest for 48 hr following surgery is incorrect. Maintaining bed rest following surgery should not be included in the plan of care. Early ambulation prevents distention and improves intestinal mobility. 8. A nurse is assisting with discharge teaching for a client who is postoperative following a laryngectomy. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) 1) To aid in swallowing food, tip the chin before swallowing. INCORRECT 2) Avoid using liquid supplements. INCORRECT 3) Include warm foods in your diet because they are easier to swallow. 4) Swallow twice after each bite. INCORRECT 5) Take a sip of water with each bite of food. Answer Rationale: To [Show Less]
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