ATI Proctored Exam Medical Surgical Form A Graded A+
A nurse is preparing to administer thrombolytic therapy to a client who had
an ischemic stroke.
... [Show More] Which of the following is an appropriate nursing action?
-Start the therapy within 8 hrs. (within 6 hrs.)
-Insert an indwelling urinary catheter after therapy begins
-Monitor blood pressure every 30 minutes during infusion.
-Elevate the head of the bed between 25 and 30 degrees (to reduce ICP &
promote venous drainage, ATI page 89)
A nurse is caring for a client who was admitted with nausea, vomiting, and a
possible bowel obstruction. An NG tube is placed and set to a low intermittent
suction. Which of the following findings should the nurse report to the provider?
-The client reports being extremely thirst with a sore throat
-The drainage is bright green in color with brown fecal material
-The amount of drainage is gradually decreasing
-The client’s abdomen becomes distended and firm.
A nurse is reviewing the medical record of a client who has diabetes insipidus.
Which of the following findings should the nurse expect?
-Elevated blood pressure
-Hypothermia
-Urine specific gravity 1.001
-Bun 15 mg/d:
The nurse is caring for a client who has hyperthyroidism and develops thyroid
storm. Which of the following instructions should the nurse give to the client
regarding management of thyroid storm?
-You will need to begin taking an ACE inhibition medication
-You will need a pacemaker to increase your heart rate
-You will need a cooling blanket to lower your body temperature
-You will need additional thyroid supplementation
The nurse is reviewing the medical record of a client who has acute gout. The
nurse should expect an increase in which of the following laboratory results?
-Uric acid
-Intrinsic factor
-Creatinine kinase
-Chloride level
A nurse is preparing to administer peritoneal dialysis to a client. Which of
the following actions should the nurse take?
-Use clean technique to access the catheter
-Chill the dialysate before administration
-Hang the drainage bag below the client’s abdomen
-Place the client in high-Fowler’s position.
A nurse in the emergency department is caring for a client who has deep
partial thickness burns over 30% of his body, including his upper chest and
abdomen. Which of the following actions is the nurse priority?
-Insert an 18-gauge IV catheter
-Administer tetanus toxoid
-Check the clients mouth for black particles
-Remove the clients burned clothing.
A nurse is presenting an in-service program about Parkinson’s disease (PD).
Which of the following statements should the nurse include in teaching?
-PD results form a decreased amount of dopamine in the client’s brain
-PD causes clients to have an increased sympathetic nervous system response
-PD results in the development of neurofibrillary tangles within the client’s brain
-PD manifestations worsen due to the clients decreased production of acetylcholine
A nurse is teaching a client about the use of an incentive spirometer. Which of
the following instructions should the nurse include in the teaching?
-Place hands on the upper abdomen during inhalation.
-Exhale slowly through pursed lips.
-Hold breath about 3 to 5 seconds before exhaling. (ATI page 138)
-Position the mouthpiece 2.5 cm (1 in) from the mouth.
A nurse is assessing a client who is 12 hr. postoperative following a colon
resection. Which of the following findings should the nurse report to the surgeon?
-Heart rate 90/mm
-Hgb 8.2 g/dL
-Gastric ph of 3.0
-Absent bowel sounds
Recall that bowel sounds are altered in patients with obstruction; absent bowel
sounds imply total obstruction. QSEN: Safety (Book page 1143)
A nurse is contacting the provider of a client who has cancer and is experiencing
breakthrough pain. Which of the following prescriptions should the nurse
anticipate?
-Intravenous dexamethasone
-Transmucosal fentanyl
-Oral acetaminophen- not strong enough
-Intramuscular meperidine
Fentanyl is a lipophilic (readily absorbed in fatty tissue) opioid and, as such, has
a fast onset and short duration of action. It is recommended opioid for patients
with end-organ failure because it has no clinically relevant metabolites. It also
produces fewer hemodynamic adverse effects than other opioids; therefore, it is
often preferred in patients who are hemodynamically unstable such as the
critically ill. (Book page 59)
A nurse is admitting a client who reports chest pain and has been placed on
a telemetry monitor. Which of the following should the nurse analyze to
determine whether the client is experiencing a myocardial infarction? [Show Less]