ATI Proctored Exam Medical Surgical Form A

1. A nurse is preparing to administer thrombolytic therapy to a client who had an ischemic stroke. 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) 2. 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. 3. 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) 4. A nurse is caring for a client who has diabetes insipidus. Which of the following medications should the nurse plan to administer? -Regular Insulin -Furosemide -Desmopressin -Lithium Carbonate Teach patients with diabetes insipidus the proper way to self-administer desmopressin orally or by nasal spray.