ATI PRACTICE FOR MED SURGE FINAL PROCTORED 2023 EXAM WITH ACCURATE ANSWERS
Question 1)
A nurse is contributing to the plan of care for an older adult
... [Show More] client who is at risk for osteoporosis. Which of the following interventions should the nurse include to prevent bone loss?
a- Increase fluid intake.(Fluid intake is beneficial for general health and wellness, and it helps to treat some disorders. Caffeine and alcohol intake can increase the client's risk of developing osteoporosis. However, fluid intake does not prevent bone loss.)
b- Encourage range-of-motion exercises.(Range-of-motion exercises are beneficial
for general health and wellness, and they help to maintain flexibility and prevent contractures. However, range-of-motion exercises do not prevent bone loss.)
c- Massage bony prominences.(Massaging bony prominences should be avoided because it can traumatize deep tissues.)
d- Encourage weight-bearing exercises.(Weight-bearing exercises, such as walking, can maintain bone mass by reducing bone demineralization, thus helping to prevent osteoporosis.)
Question 2)
A nurse is collecting data from a client and notices several skin lesion. Which of the following findings should the nurse report as possible melanoma?
a- Scaly patches(The nurse should report scaly patches as possible basal or squamous cell carcinoma.
b- Silvery white plaques(The nurse should report silvery white plaques as possible psoriasis.)
c- Irregular borders(The nurse should report irregular borders of a skin lesion to the provider because it can indicate malignant melanoma.)
d- Raised edges(The nurse should report raised edges of a skin lesion as possible basal cell carcinoma.)
Question 3)
A nurse is collecting data on a client who is scheduled for a cardiac catheterization. Which of the following laboratory levels should the nurse review prior to the procedure?
a- Albumin(Albumin levels determine the amount of protein the liver produces in the body and is an indication of hepatic function and nutritional status. However, it is not impacted by contrast media used for cardiac catheterization. Therefore, the nurse does not need to review this laboratory level prior to a cardiac catheterization.)
b- Phosphorus(Phosphorus is an electrolyte that combines with calcium to maintain bone health and is involved as an energy source in metabolism. However, it is not impacted by contrast media used for cardiac catheterization. Therefore, the nurse does not need to review this laboratory level prior to a cardiac catheterization.)
c- TSH(TSH levels determine thyroid function. However, it is not impacted by contrast media used for cardiac catheterization. Therefore, the nurse does not need to review this laboratory level prior to a cardiac catheterization.)
d- BUN(BUN levels indicate kidney function. Contrast media used during cardiac catheterization can cause renal failure. The nurse should review this laboratory level to determine if the client can tolerate the IV contrast dye during the procedure.)
Question 4)
A nurse is contributing to the plan of care for a client who has peripheral arterial disease (PAD) of the lower extremities. Which of the following interventions should the nurse include?
a- Place moist heat pads on the extremities.(The nurse should avoid applying heat to the client's extremities to prevent injury due to decreased sensation.)
b- Perform manual massage of the affected extremities.(The nurse should avoid massaging the client's lower extremities if the client is having pain from ischemia. A warm environment and keeping the client warm will help with circulation to the extremities and decrease pain through vasodilation.)
c- Dangle the extremities off the side of the bed.(The nurse should include in the plan of care to have the client dangle the lower extremities off the side of the bed to aid in reducing pain by increasing arterial blood flow. The client should not raise the lower extremities above the level of the heart when resting in bed because it impairs arterial blood flow.)
d- Apply support stockings before getting out of bed.(The nurse should avoid applying support stockings to the lower extremities because support stockings interfere with the arterial blood flow to the lower extremities.)
Question 5)
A nurse is assisting with the care of a client who has a cardiac catheterization via the right femoral artery. Which of the following actions should the nurse take to prevent postprocedure complications (Select all that apply?)
a- Should wait at least 2 hours after eating before going to bed."(The client should waitto lie down or go to bed at least 2 hr after eating to minimize reflux.)
b- "I should eat three meals a day without eating snacks between meals."(The client should eat four to six small meals per day rather than three large meals to minimize bloating and abdominal distention.)
c- "I should season my food with garlic."(The client should avoid spicy foods, including garlic, to minimize reflux.)
d- "I should drink my liquids through a straw."(The client should avoid drinking through a straw, which can promote belching and reflux.)
Question 6)
A nurse isreinforcing teaching about home care with a client who had a knee arthroplasty. Which of the following factors should the nurse identify as an indication that a barrier to learning might be present?
a- The client asks questions each time the nurse stops talking.(The nurse should identify that asking questions indicates active listening by the client and enhances learning.)
b- The client stops the nurse and asks for pain medication.(The nurse should identify that a client who is in pain will not be able to concentrate, which can interfere with his ability to learn.)
c- While the nurse is speaking, the client refers to the written materials.(The nurse should identify that clients learn in different ways. Using multiple methods of teaching, including hands-on practice and providing written materials, enhances learning.)
d- A family member who is present asks the client to repeat important points.(The nurse should identify that family member who are actively engaged in the teaching session and ask questions can enhance learning.)
A nurse is reinforcing discharge instructions with a client who is postoperative following a right hip arthroplasty. Which of the following statements should the nurse make?
a- You may cross your legs in 60 days."(The nurse should instruct the client to wait 90 days before crossing her legs. Crossing her legs early in the postoperative period can result in dislocation of the replacement hip.)
b- "Avoid lying on your operative side."(The nurse should inform the client that she may lie on her operative side with a pillow between her legs. This will not injure the suture site or cause dislocation of the replacement hip.)
c- "Avoid bending your hips more than 90 degrees."(The nurse should instruct the client to avoid bending her hips more than 90° to prevent dislocation of the replacement hip.)
d- "You may sleep on a soft mattress."(The nurse should instruct the client to sleep on a firm mattress to avoid potential dislocation of the replacement hip.)
A nurse is caring for a client who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days ago. Which of the following actions should the nurse take?
a- Perform pin site care daily.(The nurse should perform pin site care daily with chlorhexidine solution or use a solution according to facility protocol. The nurse should also monitor the pin sites for manifestations of infection.)
b- Remove the overbed trapeze.(The nurse should ensure the client has an overbed trapeze to aid in lifting the upper body off the bed when necessary and to help prevent skin breakdown of the heels and elbows with client repositioning.)
c- Remove the boot every 2 hr.(The nurse should identify that balanced suspension skeletal traction is managed through the use of pins, pulleys, weights, and frames and that the client does not wear a boot.)
d- Keep the weights on a stable, flat surface. (The nurse should ensure the weights hang freely at all times.)
A nurse is assisting the charge nurse with developing an in-service about caring for clients who have internal sealed radiation implants. Which of the following information should the nurse include?
a- Restrict the time pregnant women are allowed in the client's room to 15 min.(Pregnant women and children should not be allowed to visit a client who is receiving internal radiation therapy because of the risk for exposure to radiation emissions.)
b- Pick up a radiation implant with a double-gloved hand if it becomes dislodged.(The nurse should use forceps to pick up a radiation implant if it becomes dislodged.
c- Limit time spent in the client's room to 2 hr during an 8 hr shift.(The nurse should limit time spent in the client's room to 30 min during an 8 hr shift.)
d- Dispose of radiation implants in a lead container.(Lead impairs the emission of radiation.
Therefore, the nurse should dispose of radiation implants in a lead container in accordance with facility protocol.)
A nurse is providing discharge teaching for the family of a client who has Parkinson’s disease. Which of the following information should the nurse include in the teaching?
a- Place the client on a low-calorie diet to prevent weight gain.(The nurse should instruct the client's family to provide the client with extra calories and protein to prevent unintentional weight loss from expenditure of energy due to tremors, dyskinesia, and difficulty swallowing.)
b- Remind the client to avoid watching her feet when walking.(The nurse should instruct the client's family to frequently remind the client to maintain correct posture and prevent falls by not watching her feet when walking.)
c- Use small area rugs in the client's home for traction.(The nurse should instruct the client's family to avoid using area rugs in the client's home because her foot may drag or be stiff and catch on an area rug, which can cause a fall.)
d- Instruct the client to take tub baths instead of showers.(The nurse should instruct the family to encourage the client to take walk-in, sit-down showers, because skeletal muscle rigidity can cause difficulty in moving, coordination, and balance, which increases the risk of a fall.)
A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. Which of the following statements indicates that client is adhering to the nurse’s instructions?
a- "I apply rubbing alcohol to my feet every day to prevent infection."(Rubbing alcohol has a drying effect on skin and can increase cracking, allowing an entry point for infection. The client should apply lotions that do not contain alcohol.)
b- "I will wear clean, knee-high wool socks every day to help improve my circulation."(Wool socks can result in perspiration, which puts the client at risk for developing a fungal infection. The client should use light- weight socks to promote arterial blood flow.)
c- "I use hot water bottles to keep my feet warm at night."(Clients who have peripheral vascular disease have decreased sensation of the affected extremities. Therefore, they are unable to detect the temperature of the water bottle, which increases the risk for burns.)
d- "I don't cross my legs anymore."(Clients who have peripheral vascular disease should not cross their legs because it can impede circulation
A nurse is reinforcing teaching with a client who has heart failure and a new prescription for hydrochlorothiazide. Which of the following findings should the nurse instruct the client to report to the provider?
a- Onset of nausea(The nurse should instruct the client to report a new onset of nausea, which can be an indication of hyponatremia or hypokalemia resulting from the diuretic effects of the hydrochlorothiazide.
A nurse is caring for a client who is 13 days postoperative following a total right hip arthroplasty. Which of the following actions should the nurse take?
Maintain abduction of the client's right leg while in bed. (The nurse should maintain abduction of the client's right leg to prevent dislocation of the affected hip by placing an abductor pillow between the client's legs when resting in bed.)
A nurse is reinforcing discharge teaching with a client who has hearing loss. Which of the following actions should the nurse take when communicating with the client?
Rephrase client instructions when not understood. (When communicating with a client who has hearing loss, the nurse should rephrase, rather than repeat, discharge instructions when they are not understood.)
A nurse is caring for a client who is 1 day postoperative following a hip arthroplasty. The client is exhibiting hypotension, tachycardia, and tachypnea. The nurse should recognize that these findings indicate which of the following complications?
Pulmonary embolism (Manifestations of a pulmonary embolism include hypotension, tachycardia, and tachypnea.)
A nurse is monitoring a client who recently had a cast placed on the right lower extremity for a bone fracture. Which of the following findings should the nurse recognize as abnormal?
Lack of sensation between the first and second toes (Lack of sensation between the toes indicates peripheral nerve impairment and is an abnormal finding that can indicate the client has compartment syndrome. The nurse should notify the provider immediately.)
A nurse is collecting data from a client who has heart failure and is taking digoxin. Which of the following outcome from the medication should the nurse expect?
Decreased shortness of breath (The nurse should expect the client to have decreased shortness of breath.
Digoxin increases the contractility of the heart, which decreases pulmonary congestion.)
A nurse is reinforcing teaching with a client who has systemic lupus erythematosus (SLE) and is to begin taking methylprednisolone orally. Which of the following statements should the nurse include in the teaching?
"Limit contact with large groups of people." (Glucocorticoids cause
immunosuppression and may mask infection. The client should limit contact with sources of possible infections, such as large groups of people.)
A nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for baclofen. Which of the following instructions should the nurse include in the teaching?
Avoid stopping this medication suddenly. (The nurse should instruct the client to avoid stopping baclofen suddenly because it can result in adverse reactions, including seizures, paranoia, and hallucinations.)
A nurse is assisting with the discharge planning for a client who is postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the discharge plan?
Obtain a raised toilet seat. (The nurse should instruct the client to use a raised toilet seat to avoid flexing the hip more than 90°, which increases the risk for dislocation.)
A nurse is reinforcing teaching with a client who has mitral valve disease. Which of the following statements by the client indicates an understanding of the disease process?
"I should call my doctor if my ankles swell."(Swelling of the ankles can indicate heart failure. The client should report this finding to the provider.)
A nurse is assisting in the care of a client who has manifestations of sepsis. Which of the following provider prescriptions should the nurse implement first?
Initiate oxygen at 4 L/min via nasal cannula. (When using the airway, breathing, circulation approach to client care, the first action the nurse should take is to initiate oxygen. Clients who have manifestations of sepsis are often hypoxic, tachypneic, or have a PaCO2 level less than 32 mm Hg. The nurse should provide supplemental oxygen to keep the client's oxygen saturation levels at 95% or greater, which will maximize the ability of the hemoglobin to support the oxygen needs of the body.)
A nurse is caring for a client who is in Buck’s traction. Which of the following interventions should the nurse perform to reduce skin breakdown?
Keep the skin dry and free of perspiration. (The nurse should not leave m [Show Less]