ATI RN Medical Surgical Proctored Exam

ATI Med-Surg Proctored Exam A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of 7/min. The arterial blood gas (ABG) values include: pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Oxygen saturation 80% Bicarbonate 28 mEq/L Which of the following interpretations of the ABG values should the nurse make 1) Metabolic acidosis 2) Respiratory acidosis 3) Metabolic alkalosis 4) Respiratory alkalosis A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The nurse should recognize that which of the following statements by the client indicates a need for further teaching? 1) "I will avoid crossing my legs at the knees." 2) "I will use a thermometer to check the temperature of my bath water." 3) "I will not go barefoot." 4) "I will wear stockings with elastic tops." A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease. The client becomes agitated and combative when the nurse approaches him. Which of the following actions should the nurse plan to take? 1) Turn the water on and ask the client to test the temperature. 2) Obtain assistance to place mitten restraints on the client. 3) Firmly tell the client that good hygiene is important. 4) Calmly ask the client if he would like to listen to some music. A nurse is collecting data on a client’s wound. The nurse observes that the wound surface is covered with soft, red tissue that bleeds easily. The nurse should recognize this is a manifestation of which of the following? 1) Decreased perfusion 2) Infection 3) Granulation tissue 4) An inflammatory response A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm3. Which of the following food items brought by the family should the nurse prohibit from being given to the client? 1) Baked chicken 2) Bagels 3) A factory-sealed box of chocolates 4) Fresh fruit basket A nurse is contributing to the plan of care for an older adult client who is postoperative following a right hip arthroplasty. Which of the following interventions should the nurse include in the plan? 1) Perform the client's personal care activities for her. 2) Limit the client’s fluid intake. 3) Monitor the Homan’s sign. 4) Maintain abduction of the right hip. A nurse is caring for a client who has heart failure and respiratory arrest. Which of the following actions should the nurse take first? 1) Establish IV access. 2) Feel for a carotid pulse. 3) Establish an open airway. 4) Auscultate for breath sounds. A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longer certain he wants to have the procedure. Which of the following responses should the nurse make? 1) "Why have you changed your mind about the surgery?" 2) "Bypass surgery must be very frightening for you." 3) "Your provider would not have scheduled the surgery unless you needed it." 4) "I will call your doctor and have him discuss your surgery with you." A nurse is caring for a client who is postoperative following foot surgery and is not to bear weight on the operative foot. The nurse enters the room to discover the client hopped on one foot to the bathroom, using an IV pole for support. Which of the following actions should the nurse take? 1) Walk the client back to bed immediately and get the client a bedpan. 2) Tell the client to remain in the bathroom after toileting and obtain a wheelchair. 3) Warn the client she might have to be restrained if she gets up without assistance. 4) Keep the bathroom door open to ensure the client is okay. A nurse is assisting with the care of a client who is postoperative and has a closed- wound drainage system in place. Which of the following actions should the nurse take? 1) Fully recollapse the reservoir after emptying it. 2) Empty the reservoir once per day. 3) Replace the drainage plug after releasing hand pressure on the device. 4) Irrigate the tubing with sterile normal saline solution at least once every 8 hr. A nurse is reinforcing discharge instructions with a client who has hepatitis A. Which of the following statements by the client indicates an understanding of the teaching? 1) "I will not eat fried foods." 2) "I will abstain from sexual intercourse." 3) "I will refrain from international travel." 4) "I will not order a salad in a restaurant." A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching? 1) Rest in a supine position. 2) Consume a low-protein diet. 3) Breathe in through her nose and out through pursed lips. 4) Limit fluid intake throughout the day. A nurse is caring for a client who is postoperative and has a history Addison's disease. For which of the following manifestations should the nurse monitor? 1) Hypernatremia 2) Hypotension 3) Bradycardia 4) Hypokalemia A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is to take hydroxyzine preoperatively. Which of the following effects of the medication should the nurse include in the teaching? (Select all that apply.) 1) Decreasing anxiety 2) Controlling emesis 3) Relaxing skeletal muscles 4) Preventing surgical site infections 5) Reducing the amount of narcotics needed for pain relief A nurse is reinforcing teaching with a client who has a new prescription for epoetin alfa. The nurse should reinforce to the client to take which of the following dietary supplements with this medication? 1) Vitamin D 2) Vitamin A 3) Iron 4) Niacin A nurse is caring for a client after a radical neck dissection. To which of the following should the nurse give priority in the immediate postoperative per