ATI MED SURG 324 UPDATED EXAM WITH RATIONALE PROVIDED
1.) A nurse is teaching a client who has type 2 diabetes mellitus about foot care. Which of the
... [Show More] following statements by the client indicates an understanding of the teaching?
● I will apply moisturizer between my toes
● I will soak my feet daily
● Ill be sure to wear cotton socks every day
● Ill use a heating pad to warm my feet
Rationale: The nurse should instruct the client to wear clean cotton socks every day to absorb moisture and reduce the risk of infection.
2.) A nurse is providing discharge teaching for a client who had a left total hip arthroplasty. Which of the following client statements indicates the teaching was effective?
● I should expect swelling of the affected leg for several weeks
● I should not cross my legs at the ankles or knees
● I will inspect my hip incision every other day for redness
● I can bend over at the hip to pick up objects
Rationale: The nurse should instruct the client to avoid crossing the legs at the knees or ankles because this can result in the dislocation of the femoral head.
3.) A nurse is providing discharge instructions to a client who has a new laryngectomy. The nurse should tell the client to be careful while bathing to prevent which of the following complications?
● Aspiration of water
● Infection of the stoma
● Bleeding around the stoma
● Skin breakdown around the stoma
Rationale: The client should be careful during bathing and showering and should avoid swimming due to the risk of aspiration of water. The client should use a shower shield over the stoma when bathing or showering to keep water out of the airway.
4.) A nurse is assessing the hematologic system of an older adult client. The nurse should report which of the following findings to the provider as a possible indication of a hematologic disorder?
● Pallor
● Jaundice
● Absence of hair on the legs
● Poor nailbed capillary
Rationale: A progressive loss of hair is common with aging. However, thinning or absence of hair on the extremities indicates poor arterial circulation to that area. The nurse should look for further indications of arterial insufficiency and report these findings to the provider.
5.) A nurse is providing post-procedural teaching to a client who had a diagnostic knee arthroscopy. Which of the following statements indicates that the client understands the nurse’s instructions? [Show Less]