ATI RN MEDICAL SURGERY PROCTORED EXAM 2019 WITH VERIFIED EXPERT ANSWERS
38. A nurse is assessing a client following the insertion of a central venous
... [Show More] catheter. Which of the following
findings indicates a pneumothorax?
a. Diminished breath sounds
b. Distended neck veins
c. Irregular heart rate
d. Itching over the incision
S/S of pneumothorax
● Signs of respiratory distress (tachypnea, tachycardia, hypoxia, cyanosis, dyspnea, and use of accessory
muscles)
● Tracheal deviation to the UNAFFECTED side (tension pneumothorax)
● REDUCED or ABSENT breath sounds on the affected side
39. A nurse is caring for a client who is 2 days postoperative following below the knee amputation and asks
about the purpose of maintaining an elastic bandage around residual limb of the extremity. Which of the
following is an appropriate response by the nurse?
a. The elastic bandage will prevent a postoperative wound infection
b. The elastic bandage will prevent excessive edema – pg.442
c. The elastic bandage will keep you from seeing the surgical site
d. The elastic bandage will keep the sutures from loosening
40. A nurse is assessing a client who has malnutrition. Which of the following findings should the nurse
expect?
a. Hyperproteinemia
b. Cachexia
c. Diplopia
d. Hypermagnesemia
muscle wasting syndrome is loss of weight, muscle atrophy, fatigue, weakness, and significant loss of appetite in
someone who is not actively trying to lose weight
41. A nurse is caring for a client who is receiving chemotherapy and requests information about acupuncture
to relieve some of the side effects. Which of the following findings should the nurse identify as a
contraindication to receiving this alternative therapy?
a. Lymphedema
b. Urticaria
c. Mouth sores
d. Headaches
42. A nurse is providing discharge teaching to a client who has an ileostomy. Which of the following client
statements indicates an understanding of the teaching?
a. I will take a laxative when I am constipated
b. I will expect my stools to be loose – pg.533
c. I will eat a higher-fiber diet
d. I will empty my bag when it is full
43. A nurse is providing instructions about foot care for a client who has peripheral disease. The nurse should
identify that which of the following statements by the client indicates an understanding of the teaching?
a. I soak my feet in hot water before trimming my toenails
b. I rest in my recliner with my feet elevated for about an hour every afternoon
c. I use my heating pad on low setting to keep my feet warm.
d. I apply a lubricating lotion to the cracked area on the soles of my feet – NOT CORRECT
44. A nurse is planning care for a client who has a pulmonary embolism and a prescription for enoxaparin via
subcutaneous injection. Which of the following interventions should the nurse include?
a. Assess the client’s tools for occult blood
b. Massage the injection site
c. Instruct the client to limit vitamin K intake [Show Less]