ATI - Adult Medical Surgical NGN, Exam Questions & Answers-A nurse is providing teaching to a client who is perimenopausal and has a prescription for
... [Show More] hormone replacement therapy. For which of the following adverse effects should the nurse instruct the client to notify the provider?
- Calf pain
Numbness in the arms
Intense headache
A nurse is planning care for a client who is postoperative following a laparotomy and has a closed-suction drain. Which of the following actions should the nurse take to manage the drain?
- Compress the drain reservoir after emptying.
A nurse is caring for a client who has DKA. Which of the following findings should indicate to the nurse that the client's condition is improving?
Glucose 272 mg/dL
A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr ago. The nurse should identify which of the following findings as an indication of a myocardial infarction (MI)?
- Troponin I 8 ng/mL
A nurse is planning a health promotional presentation for a group of African American clients at a community center. Which of the following disorders presents the greatest risk to this group of clients?
- hypertension
A nurse is providing education to a client who is at risk for osteoporosis. Which of the following instructions should the nurse include?
- Walk for 30 min four times per week.
A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse take?
- Place a pressure bag around the flush solution.
A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the following results should the nurse expect?
- PaCO2 56
A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the following instructions should the nurse include?
- Flex the foot every hour when awake.
A nurse is planning care for a client who is postoperative following a parathyroidectomy. Which of the following actions should the nurse identify as the priority?
- Place a tracheostomy tray at the bedside.
A nurse is evaluating the plan of care for four clients after 2 days of hospitalization. The nurse should identify the need to revise the plan for which of the following clients? - A client who is postoperative following abdominal surgery and reports feeling that something "popped" when they coughed
A nurse is checking the ECG rhythm strip for a client who has a temporary pacemaker. The nurse notes a pacemaker artifact followed by a QRS complex. Which of the following actions should the nurse take? - Document that depolarization has occurred.
A nurse is providing discharge instructions to a client who has active tuberculosis (TB). Which of the following information should the nurse include in the instructions? - Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures.
A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions should the nurse anticipate taking? - Slow the infusion rate
A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the nurse's priority? - Temperature 38.9° C (102° F)
A nurse is caring for a client who has homonymous hemianopsia as a result of a stroke. To reduce the risk of falls when ambulating, the nurse should provide which of the following instructions to the client? - Scan the environment by turning your head from side to side.
A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The client's initial vital signs were heart rate 80/min, blood pressure 130/70 mm Hg, respiratory rate 16/min, and temperature 36° C (96.80 F). Which of the following vital sign changes should alert the nurse that the client might be hemorrhaging? - Heart rate 110/min
A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The client is unable to void on the bedpan. Which of the following actions should the nurse take first? - Scan the bladder with a portable ultrasound.
A nurse is assessing a client who has advanced lung cancer and is receiving palliative care. The client has just undergone thoracentesis. The nurse should expect a reduction in which of the following common manifestations of advanced cancer? - Dyspnea
A nurse is caring for a client who is postoperative. - Nurses' Notes
Client admitted to medical-surgical unit from PACU. Client reports incisional pain as 2 on a scale of 0 to 10. Client appears restless and frequently asks for water. Bilateral lower extremities cool with +1 pedal pulses. Urine output is 40 mL for the past 2 hr. Moderate amount of bright red drainage noted on surgical incision dressing.
Vital Signs
Temperature 37.6° C (99.7° F)
Heart rate 114/min
Respiratory rate 22/min
Blood pressure 88/54 mm Hg
Oxygen saturation 93% on room air
Diagnostic Results
Hgb 18 g/dL (12 to 16 g/dL)
Hct 54% (37% to 47 %)
Total WBC count 11,000/mm3 (5,000 to 10,000/mm3)
Troponin T 0.04 ng/mL (less than 0.1 ng/mL)
Medical History.
History of hypertension. Acute myocardial infarction 1 year ago.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress. - The nurse should insert a large-gauge IV and initiate a fluid challenge because the client is most likely experiencing hypovolemia as evidenced by the client's restlessness, tachycardia, hypotension, decreased pulses, cool extremities, and decreased urine output. The nurse should monitor the client's urine output and blood pressure to evaluate the effectiveness of treatment.
A home health nurse is providing teaching to a client who has a stage 1 pressure injury on the greater trochanter of his left hip. Which of the following instructions should the nurse include in the teaching? - Change position every hour
A nurse is performing a preoperative assessment for a client. The nurse should identify that an allergy to which of the following foods can indicate a latex allergy? - avocados
- Vital Signs
Blood pressure 155/98 mm Hg
Heart rate 98/min
Respiratory rate 14/min
Temperature 38.4° C (101.1 ° F)
Medication Administration Record
Gentamicin 60 mg intermittent IV bolus Q8H
Ceftriaxone 1 g intermittent IV bolus BID
Morphine 2.5 mg IV bolus Q3H PRN for pain
Acetaminophen 650 mg PO Q6H PRN for fever greater than 38°C (100.4° F)
Laboratory Results
WBC count 13,700/mm3
Serum creatinine 2.1 mg/dL
Hemoglobin 10 g/dL
A nurse is reviewing the medical record of a client who has osteomyelitis and a prescription for gentamicin. Which of the following findings from the client's medical record should indicate to the nurse the need to withhold the medication and notify the provider? - Serum creatinine
A nurse is obtaining a medication history from a client who is scheduled to undergo cataract surgery. The nurse should recognize that which of the following client medications is a contraindication for the surgery and notify the provider? - Warfarin [Show Less]