NURS 272 Final (W9)
ATI RN Adult Medical Surgical Online Practice
NURS-272_Final (W9) - ATI (RN Adult Medical Surgical Online
... [Show More] Practice
Terms in this set (90)
AMS16B-1
A nurse is providing dietary teaching to a patient who has
celiac disease. Which of the following food choices should the nurse identify as an
indication that the patient understands the teaching?
A. Chocolate pudding
B. Grilled chicken breast
C. Macaroni and cheese
D. Peanut butter and saltine crackers
Answer: B
A-Chocolate pudding contains wheat starch, which is a source of gluten and can cause an exacerbation of celiac disease. An alternative dessert choice is tapioca, which does not contain gluten.
B-Clients who have celiac disease should avoid food that contains gluten. In a person who has celiac disease, gluten causes
inflammation of the small intestine mucosa and can increase the risk of cancer. A grilled chicken breast does not contain gluten and is, therefore, a good food choice.
C-Macaroni contains a wheat product, which is a source of gluten and can cause an exacerbation of celiac disease. Alternatives to wheat flour include rice flour and corn flour.
D-Saltine crackers contain a wheat product, which is a source of gluten and can cause an exacerbation of celiac disease. The nurse should instruct the client to avoid products
that contain wheat, barley, and rye.
[AMS16B-1 - RN Adult Medical Surgical Nursing (10.0); p
AMS16B-2
A nurse is
developing a teaching plan for a patient who has
gout. Which of the following recommendations should the nurse
include?
A. Take a daily aspirin
B. Decreased intake of purine meats
C. Avoid milk products
D. Take allopurinol for an acute attack
Answer: B
A-A client who has gout should avoid aspirin and diuretics as these medications are known to precipitate an attack that causes pain and
inflammation in the joints.
B-A client who has gout should follow a low- purine diet and avoid foods, such as organ meats and shellfish, to prevent precipitating an attack that causes pain and inflammation in the joints.
C-Clients who have gout should eat and drink foods—such as citrus fruits and juices, milk,
and other dairy products—that increase the urinary pH. Increasing urinary pH decreases the risk of precipitating an attack that causes pain and inflammation in the joints.
D-A client who experiences an acute attack of gout should take prescribed colchicine,
indomethacin, or a corticosteroid. Allopurinol is used to lower uric acid after the initial manifestations of an acute attack have resolved.
[AMS16B-2 - RN Adult Medical Surgical Nursing (10.0); p
AMS16B-3
A nurse is assessing a client who has a comminuted fracture of the femur. Which of the following findings should the nurse identify as an early manifestation of a fat embolism?
A. Dyspnea
Answer: A
A-Fat embolisms originate in the yellow bone marrow and travel through the vascular system, clogging small vessels. Dyspnea,
along with tachypnea and a decreased arterial oxygen level, is an early manifestation of a fat embolism.
B-During the later stages of the process, the client can develop a fever, often higher than 39.5º C (103º F).
C-Petechiae, a red-brown measles-like rash, is
B. Fever
C. Petechiae on the chest
D. Fat globules in the urine
usually the last manifestation of a fat embolism to occur. Petechiae can appear on the conjunctiva, hard palate, neck, chest, axilla, or anterior upper arms.
D-Fat globules can be observed in some cases of fat embolism. The fat globules appear in the urine when the fat is filtered by the renal tubules and excreted. However, this is not an early manifestation.
[AMS16B-3 - RN Adult Medical Surgical Nursing (10.0); p
AMS16B-4
A nurse is caring for a patient who has cervical spinal cord injury sustained 1
month ago. Which of the following manifestations
indicates that the
client is experiencing autonomic
dysreflexia (AD)?
A. Temperature 38.8°C or 102°F
B. Systolic blood
pressure 70 mmHg
C. Heart rate 52/min
D. Respiratory rate 8/min
Answer: C
AD is an exaggerated response to stimuli in clients who have high level spinal injuries.
Untreated, AD can result in stroke, organ damage, or death. Manifestations of AD include diaphoresis above the site of the
spinal cord injury, but an elevated temperature is not a manifestation of AD.
Systolic blood pressure 70 mm HgA client who has a spinal injury that involves cervical or high thoracic vertebrae can experience AD
any time after the shock of the initial spinal injury. A hallmark manifestation of AD is a
sudden, significant rise in systolic and diastolic pressures.
Heart rate 52/minMY ANSWERA client who is experiencing AD will exhibit multiple manifestations, including bradycardia, severe headache, and flushing.
Respiratory rate 8/minAnxiety is a manifestation of AD. Therefore, the nurse
should expect the client to exhibit tachypnea, rather than bradypnea.
signs of autonomic dysreflexia include
bradycardia, severe headache, and flushing
[AMS16B-4 - RN Adult Medical Surgical Nursing (10.0); p
AMS16B-5
A nurse is caring for a client who has
pancreatitis. The nurse should expect which of the following laboratory results to be below the expected reference range?
A. Amylase
B. Alkaline phosphate
C. Bilirubin
D. Calcium
Answer: D
An elevated amylase level is an expected finding in a client who has pancreatitis due to injured pancreatic cells.
Alkaline phosphataseAn elevated alkaline
phosphatase level is an expected finding in a client who has pancreatitis with biliary
involvement.
BilirubinAn elevated bilirubin level is an expected finding in a client who has pancreatitis with biliary involvement.
CalciumMY ANSWERA client who has
pancreatitis is expected to have decreased calcium and magnesium levels due to fat necrosis.
pancreatitis causes decreased calcium and magnesium levels due to fat necrosis
[AMS16B-5 - RN Adult Medical Surgical Nursing (10.0); p
AMS16B-6
A nurse is preparing to give amikacin 500 mg by intermittent IV bolus to a client.
Available is amikacin 500 mg in dextrose 5% in water (D5W)
200 mL to infuse over 30 min. The nurse should set the IV
pump to deliver how
400 mL/hr
STEP 1: What is the unit of measurement the nurse should calculate? mL/hr
TEP 2: What is the volume the nurse should infuse? 200 mL
STEP 3: What is the total infusion time? 30 min STEP 4: Should the nurse convert the units of measurement? Yes (min ≠ hr) 60 min/30 min = 1 hr/X hr X = 0.5 hr
STEP 5: Set up an equation and solve for X. Volume (mL)/Time (hr) = X mL/hr 200 mL/0.5 hr
many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it
applies. Do not use a trailing zero.)
= X mL/hr X = 400
STEP 6: Round if necessary.
STEP 7: Reassess to determine whether the amount to administer makes sense. If the
prescription reads amikacin 500 mg in D5W 200 mL to infuse over 30 min, it makes sense
to administer 400 mL/hr. The nurse should set the IV pump to deliver amikacin 500 mg in D5W 200 mL at 400 mL/hr.
[AMS16B-6 - RN Adult Medical Surgical Nursing (10.0); p
AMS16B-7
A nurse is providing teaching to a client who has a recent
diagnosis of constipation-
predominant irritable bowel syndrome.
Which of the following instruction should the nurse
include in the teaching?
A. Take calcium
antacid before meals and at bedtime
B. Consume at least 30 g of fiber daily
C. Take a stimulant laxative daily
D. Consume no more than 1,000 mL of water per day
Answer: B
Calcium antacids are used to manage the manifestations of gastric reflux and dyspepsia, not constipation. Furthermore, the major
adverse effect of calcium antacids is constipation.
Consume at least 30 g of fiber daily.MY ANSWERIrritable bowel syndrome is a
gastrointestinal disorder characterized by abdominal pain, bloating, and either
constipation or diarrhea or a mixture of both. Consuming a diet high in dietary fiber helps produce bulky, soft stools and establish regular bowel patterns.
Take a stimulant laxative daily.Stimulant
laxatives are not for long-term use. The client should take a bulk-forming laxative with a full glass of water at mealtimes to help maintain bulky, soft stools.
Consume no more than 1,000 mL of water per day.The nurse should instruct the client to
drink at least 1,500 mL of fluid to promote normal bowel function and prevent
constipation.
AMS16B-8
A nurse is teaching a client who has a cardiac dysrhythmia
about the purpose of undergoing continuous telemetry monitoring. Which of the following statements by the
client reflects an
understanding of the teaching?
A. "This measures how much blood my heart is pumping."
B. "This identifies if I have a defective heart valve."
C. "This identifies if
the pacemaker cells of my heart are working properly."
D. "This measures the blood circulating to my heart muscle."
[AMS16B-7 - RN Adult Medical Surgical Nursing (10.0); p
Answer: C
Cardiac output, which is calculated by multiplying heart rate and stroke volume,
measures the amount of blood ejected by the heart over 1 min.
"This identifies if I have a defective heart valve."An echocardiogram, a non-invasive
ultrasound procedure, evaluates heart valve function and structure.
"This identifies if the pacemaker cells of my heart are working properly."MY
ANSWERTelemetry detects the ability of cardiac cells to generate a spontaneous and
repetitive electrical impulse through the heart muscle.
"This measures the blood circulating to my heart muscle."Cardiac catheterization allows for the measurement of coronary artery blood flow.
telemetry detects the ability of cardiac cells to generate a spontaneous and repetitive electrical impulse through the heart muscle
[AMS16B-8 - RN Adult Medical Surgical Nursing (10.0); p
AMS16B-9
A nurse is planning care for a client who has community- acquired pneumonia. Which of the following
intervention should the nurse include in
Answer: Monitor the patient for confusion.
Pneumonia is an inflammatory process
resulting in increased exudate and a thickening and narrowing of the airways, which causes hypoxia. The reduced oxygen level places the client at risk for confusion.
Encourage the client to use an incentive spirometer every 8 hr.The nurse should
the plan of care?
A. Monitor the client for confusion
B. Encourage the client to use an
incentive spirometer every 8 hr
C. Instruct the client to drink 1 L of fluids daily
D. Titrate the oxygen to maintain SaO2 level at 92%
encourage the client to use an incentive spirometer every hour while awake to improve her ability to deep breathe and to prevent
alveolar collapse.
Instruct the client to drink 1 L of fluids daily.The nurse should instruct the client to drink at least 2 L of fluid daily to prevent dehydration and
decrease the thickness of the secretions.
Titrate the oxygen to maintain the SaO2 level at 92%.The nurse should titrate the oxygen to maintain an SaO2 level of at least 95% to
prevent hypoxia.
pneumonia is an inflammatory process
resulting in increased exudate and a thickening and narrowing of the airways, which causes hypoxia. The reduced O2 level places the
patient at risk for confusion
[AMS16B-9 - RN Adult Medical Surgical Nursing (10.0); p
AMS16B-10 / AMS19A-*
A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing's triad?
A. Hypotension
B. Tachypnea
C. Nuchal rigidity
D. Bradycardia
Answer: D
A-A client who has increased intracranial pressure from a traumatic brain injury can develop hypertension, which is one component of Cushing's triad.
B-A client who has a traumatic brain injury can develop decreased cerebral blood flow, which results in increased arterial pressure.
The changes to arterial pressure cause changes in blood pressure. However, respirations are not affected.
C-Nuchal rigidity, or neck stiffness, is an indication of meningitis.
D-A client who has increased intracranial pressure from a traumatic brain injury can
develop bradycardia, which is one component of Cushing's triad. The other components of
Cushing's triad are severe hypertension and a widened pulse pressure.
[AMS16B-10 / AMS19A-* - RN Adult Medical Surgical Nursing (10.0); p75]
AMS16B-11
A nurse is
administering meperidine IM in the right deltoid of a
client. The nurse
aspirates and pulls back blood in the syringe. Which of the following actions should the nurse
take?
A. Obtain a new needle and continue administering the medication as
prescribed.
B. Withdraw the syringe and reinsert it in a different location.
C. Continue with the injection after pulling back on the needle slightly.
D. Dispose of the medication.
Answer: D
The presence of blood indicates improper needle placement. The nurse should recognize that the medication is now contaminated.
Withdraw the syringe and reinsert it in a
different location.The nurse should recognize that the needle is contaminated and not reuse it.
Continue with the injection after pulling back on the needle slightly.The presence of blood indicates improper needle placement.
Continuing with the injection could result in administering the medication IV, which is the incorrect route.
Dispose of the medication.MY ANSWERThe
presence of blood indicates improper needle placement. The medication and needle are now contaminated. The nurse should dispose of the medication according to facility
protocol and obtain a new dose of medication, syringe, and needle.
[AMS16B-11 - RN Adult Medical Surgical Nursing (10.0); p
AMS16B-12
A nurse is providing teaching to a client who is receiving
Answer: A
The client should monitor his blood pressure while taking this medication because
chemotherapy and has a new
prescription for epoetin alfa. Which of the following
client statements indicates an
understanding of the teaching?
A. "I will monitor my blood pressure while taking this
medication"
B. "I should take a vitamin D supplement to
increase the effectiveness of the medication"
C. "An increase in my appetite indicates
that the medication has reached a toxic level."
D. "I will decrease the amount of
protein in my diet while taking this medication"
hypertension is a common adverse effect and can lead to hypertensive encephalopathy.
"I should take a vitamin D supplement to increase the effectiveness of the
medication."The client requires an adequate
intake of iron, folic acid, and vitamin B12 while taking this medication because they are essential to the production of erythrocytes. "An increase in my appetite indicates that the medication has reached a toxic level."An
increase in appetite is an indication of a therapeutic response to the medication.
"I will decrease the amount of protein in my diet while taking this medication."The client should increase the amount of protein in his diet while receiving chemotherapy to
decrease his risk for infection.
[AMS16B-12 - RN Adult Medical Surgical Nursing (10.0); p
AMS16B-13 / AMS19A-17
A nurse is caring for a client who is
undergoing [renal] hemodialysis to treat end-stage kidney
disease (ESKD). The client reports muscle
Answer: D
A-A client who has ESKD is at risk for anemia manifested by malaise, fatigue, and activity
intolerance. The nurse should plan to
administer an erythrocyte-stimulating agent, such as epoetin alfa, to a client who has
anemia.
B-A client who has ESKD can develop
cramps and a tingling sensation in [his]
their hands. Which of the following medications should
the nurse plan to administer?
A. Epoetin alfa
B. Furosemide
C. Captopril
D. Calcium carbonate
pulmonary edema manifested by restlessness, shortness of breath, crackles, and blood-
tinged sputum. The nurse should plan to
administer a loop diuretic, such as furosemide, to a client who has pulmonary edema.
C-A client who has ESKD often is hypertensive, which can further damage renal function. The nurse should plan to administer an antihypertensive medication, such as captopril, to a client who is hypertensive.
D-Hypocalcemia is a manifestation of ESKD and an adverse effect of dialysis. Often occurring late in the dialysis session, hypocalcemia can cause the client to experience muscle cramping and tingling to extremities. The nurse should plan to
administer a calcium supplement, such as calcium carbonate, as a calcium replacement.
[AMS16B-13 / AMS19A-17 - RN Adult Medical Surgical Nursing (10.0); p
AMS16B-14
A nurse is providing teaching to a client who is at risk for
developing type 1 diabetes mellitus.
The nurse should
inform the client that which of the following
manifestations
indicate diabetes? (Select all that
apply.)
A. Polyuria
B. Dysphagia
C. Polydipsia
Answer: A, C, E
Polyuria is correct. Excessive urination is a common manifestation of type 1 diabetes mellitus and is caused by increased glucose levels in the blood and urine having an
osmotic effect and pulling more water into the system.Dysphagia is incorrect. Type 1 diabetes mellitus does not impact swallowing ability.
Polydipsia is correct. Thirst is a common manifestation of type 1 diabetes mellitus
because the increased glucose levels create intracellular dehydration as water is
osmotically pulled into circulation. This cellular action stimulates the hypothalamus, creating
the sensation of thirst. Photophobia is
incorrect. Type 1 diabetes mellitus does not cause sensitivity to light. Neuropathy is
D. Photophobia
E. Neuropathy
correct. Elevated glucose levels associated with type 1 diabetes mellitus cause changes to the microvasculature. The subsequent damage to the neurons and neuronal pathways results in diabetic neuropathy, characterized by
burning, tingling, or the absence of feeling.
[AMS16B-14 - RN Adult Medical Surgical Nursing (10.0); p
A nurse is caring for a patient who is experiencing acute MI. The nurse should identify which of the following findings as manifestation of cardiogenic shock?
A. Hypotension
B. Bradypnea
C. Warm dry skin
D. Increased urinary output
A. Hypotension
[AMS16B-* - RN Adult Medical Surgical Nursing (10.0); p
THIS SET IS OFTEN IN FOLDERS WITH... [Show Less]