(solved) ATI MED SURGE PROCTORED EXAM 200 PLUS Q&A GRADED 100%

VERSION 1 135 QUESTIONS & ANSWERS A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching? 1) Take temperature once a day. 2) Wash the armpits and genitals with a gentle cleanser daily. 3) Change the litter boxes while wearing gloves. 4) Wash dishes in warm water. 1. A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions? 1) Provide humidified oxygen. → want to hyperoxygenate prior to suction 2) Perform chest physiotherapy prior to suctioning. 3) Prelubricate the suction catheter tip with sterile saline when suctioning the airway. 4) Hyperventilate the client with 100% oxygen before suctioning the airway.. 2. Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort? 1) Rub the client's feet briskly for several minutes. 2) Obtain a pair of slipper socks for the client. 3) Increase the client's oral fluid intake. 4) Place a moist heating pad under the client's feet. 3. A nurse is caring for a client who is 4 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for the nurse report to the provider? 1) Emesis of 100 mL 2) Oral temperature of 37.5° C (99.5° F) 3) Thick, red-colored urine 4) Pain level of 4 on a 0 to 10 rating scale 4. A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of the hypothermia blanket? 1) Shivering → The process of shivering is detrimental since it counteracts cooling induction, consumes energy, and can contribute to increased ICP, increased energy expenditure and brain O2 consumption. 2) Infection 3) Burns Downloaded by: tbosse4 | Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material 4) Hypervolemia 5. A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? 1) "I will carry a complex carbohydrate snack with me when I exercise." 2) "I should exercise first thing in the morning before eating breakfast." 3) "I should avoid injecting insulin into my thigh if I am going to go running." 4) "I will not exercise if my urine is positive for ketones." → not having enough insulin to use, the sugar in the blood can also cause the body to burn fat for fuel. When the body starts to burn fat for fuel, substances called ketones are produced. People w/diabetes shouldn’t exercise if the have high levels of ketones in their blood because it can make them really sick & cause their insulin levels to increase. 6. A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first? 1) Cover the client's wound with a moist, sterile dressing. 2) Have the client lie supine with knees flexed. 3) Check the client's vital signs. 4) Inform the client about the need to return to surgery. 7. A nurse is collecting data from a client who has alcohol use disorder and is experiencing metabolic acidosis. Which of the following manifestations should the nurse expect? 1) Cool, clammy skin. 2) Hyperventilation → S/Sx of Metabolic Acidosis: jaundice, tachycardia (inc. HR) Confusion, fatigue, rapid and shallow breathing, headache, sleepiness, 3) Increased blood pressure 4) Bradycardia 8. A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching? 1) Avoid bending at the waist. → brings more pressure to the eyes; bending over can cause a rush of blood to your head that interferes with recovery 2) Remove the eye shield at bedtime. 3) Limit the use of laxatives if constipated. 4) Seeing flashes of light is an expected finding following extraction. 9. A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first? 1) Suggest that the client rests before eating the meal. 2) Request a dietary consult. 3) Check the client's vital signs. → adverse effect of digoxin can be nausea, and with them being in heart failure it increases their risk of digoxin toxicity 4) Request an order for an antiemetic. Downloaded by: tbosse4 | Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material 10.A nurse is caring for a client who is 3 days postoperative following a cholecystectomy (gallbladder removal). The nurse suspects the client's wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found? 1) Sanguineous - bright red 2) Serous - clear drainage 3) Serosanguineous - pink-tinged drainage, but can look clear 4) Purulent - white, yellow or brown thick fluid (sign of an infection) 11.A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent postoperative complications which of the following actions should be reinforced during the teaching? 1) Administer an opioid analgesic to the client 30 min prior to initiating CPM (continuous passive motion) exercises. 2) Place the client’s affected leg into the CPM machine with the machine in the flexed position. 3) Place the client into a high Fowler’s position when initiating the CPM exercises. 4) Align the joints of the CPM machine with the knee gatch in the client’s bed. 12.A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.) 1) Dyspnea 2) Barrel chest 3) Clubbing of the fingers 4) Shallow respirations → Emphysema, think about “pink puffer”: difficulty catching their breath, faces redden while gasping for air, clubbing at fingers & look barrel chested 5) Bradycardia 13.A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client's right nostril. Which of the following actions should the nurse take first? 1) Take the client's temperature. 2) Place a dressing under the client's nose. 3) Notify the charge nurse. 4) Test the drainage for glucose. Downloaded by: tbosse4 | Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material 14.A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia? 1) Monitor for elevated blood pressure. 2) Provide analgesia for headaches. 3) Prevent bladder distention. 4) Elevate the client's head. 15.A nurse is caring for a client who is being evaluated for endometrial cancer. Which of the following findings should the nurse expect the client to report? 1) Hot flashes 2) Recurrent urinary tract infections 3) Blood in the stool 4) Abnormal vaginal bleeding → endometrial lining of the vaginal wall 16.A nurse is caring for a client following an open reduction and internal fixation of a fractured femur. Which of the following findings is the nurse's priority? 1) Altered level of consciousness 2) Oral temperature of 37.7° C (100° C) 3) Muscle spasms 4) Headache 17.A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge resection of the left lung and has a chest tube to suction. Which of the following is the priority finding the nurse should report to the provider? 1) Abdomen is distended → abdominal distention could be indicative of bleeding (in the 3rd cavity; rigid/distended) 2) Chest tube drainage of 70 mL in the last hour 3) Subcutaneous emphysema is noted to the left chest wall 4) Pain level of 6 on a 0 to 10 scale 18.A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching? 1) Change the ostomy pouch daily. 2) Empty the ostomy pouch when it is 2/3 full. → ⅓ full drain 3) Trim the opening of the ostomy seal to be 1/2 in. wider than the stoma. → ⅛ inches 4) Apply lotion to the peristomal skin when changing the ostomy pouch. 19.A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland. Which of the following actions should the nurse include in the plan? 1) Position the client supine while in bed. 2) Change the nasal drip pad as needed. 3) Encourage frequent brushing of teeth. 4) Encourage the client to cough every 2 hr following surgery. 20.A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily following a myocardial infarction. The nurse should instruct the client that aspirin is prescribed for clients who have coronary artery disease for which of the following effects? 1) To provide analgesia 2) To reduce inflammation 3) To prevent blood clotting → Aspirin used for MI, as a blood thinner 4) To prevent fever 21. A nurse is collecting data from a client who has open-angle glaucoma. Which of the following findings should the nurse expect? → Glaucoma = high eye pressure b/c optic nerve is damaged: causes blindness & loss of peripheral vision 1) Loss of peripheral vision 2) Headache 3) Halos around lights → cataracts & closed-angle glaucoma 4) Discomfort in the eyes 22.A nurse is collecting data from a client who has acute gastroenteritis. Which of the following data collection findings should the nurse identify as the priority? 1) Weight loss of 3% of total body weight. 2) Blood glucose 150 mg/dL. → 70-105 = normal glucose range 3) Potassium 2.5 mEq/L 4) Urine specific gravity 1.035 → 1.005-1.03 = normal range (the higher it is, the more dehydrated you are) 23.A nurse is reinforcing discharge teaching with a client who had a total abdominal hysterectomy and a vaginal repair. Which of the following statements by the client indicates a need for further teaching? 1) "I should increase my intake of protein and vitamin C." 2) "I will no longer have menstrual periods." 3) "Once I am able to resume sexual activity, I can use a water-based lubricant if I experience discomfort." 4) "I will take a tub bath instead of a shower." → no bath because risk of bacteria & infection 24.A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction. Which of the following actions should the nurse take? 1) Loosen the knots on the ropes if the client is experiencing pain. 2) Ensure the client’s weights are hanging freely from the bed. Downloaded by: tbosse4 | Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material 3) Check the client’s bony prominences every 12 hr. 4) Cleanse the client’s pin sites with povidone-iodine. 25.A nurse in a provider’s office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include? 1) Take this medication between meals. → to minimize GI upset 2) Limit intake of Vitamin C while taking this medication. 3) Take this medication with milk. 4) Limit intake of whole grains while taking this medication. 27.A nurse is reviewing the plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse recommend? (bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin) 1) Apply topical antifungal agents. 2) Apply fresh ice packs every 4 hr. 3) Wash daily with an antibacterial soap. - 4) Keep draining lesions uncovered to air dry. - no so it doesnt dry out 28.A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy established. Which of the following instructions should the nurse include in the teaching? 1) Empty the pouch immediately after meals. 2) Change the entire appliance once a day. 3) Limit fluid intake. 4) Avoid medications in capsule or enteric (Ex. Advil) form. → b/c of the poor absorpency & insufficient release of the active ingredient 29.A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for an escharotomy and wants to know what the procedure involves. Which of the following statements is appropriate for the nurse to make? 1) "An escharotomy surgically removes dead tissue." → this would be debridement 2) "A cannula will be inserted into the bone to infuse fluids and antibiotics." → a large bore IV/PICC line 3) "A piece of skin will be removed and grafted over the burned area." → skin graft 4) "Large incisions will be made in the burned tissue to improve circulation." → the eschar, by virtue of its inelasticity, results in the burn-induced compartment syndrome 30.A nurse is collecting data from a client who has a possible cataract. Which of the following manifestations should the nurse expect the client to report? 1) Decreased color perception → cataracts 2) Loss of peripheral vision → glaucoma 3) Bright flashes of light → Retinal detachment 4) Eyestrain 31.A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the following interventions should the nurse include in the plan of care? 1) Measure abdominal girth daily. 2) Use sterile water to irrigate the nasogastric tube.. 3) Maintain the client in Fowler’s position. 4) Moisten the client’s lips with lemon-glycerin swabs. 32.A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical manifestations should the nurse expect to observe? (Select all that apply.) 1) Buffalo hump 2) Purple striations 3) Moon face 4) Tremors 5) Obese extremities 33.A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following actions should the nurse take? 1) Provide a diet high in protein. → no b/c kidneys can’t excrete 2) Provide ibuprofen for retroperitoneal discomfort. → no b/c could harm liver & kidney 3) Monitor intake and output hourly 4) Encourage the client to consume at least 2 L of fluid daily. → dont want to overload with fluids if the kidneys aren’t excreting 34.A nurse is reinforcing teaching about an esophagogastroduodenoscopy with a client who has upper gastric pain. Which of the following statements should the nurse include in the teaching? 1) "A flexible tube is introduced through the nose during the procedure." → no, going through the mouth 2) "During the procedure you are in a sitting position." → supine position 3) "You will remain NPO for 8 hours before the procedure." 4) "You will be awake while the procedure is performed." → will be sedated 35.A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should Downloaded by: tbosse4 | Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material the nurse use when documenting this finding in the medical record? 1) Aura phase 2) Presence of automatisms 3) Postictal phase 4) Presence of absence seizures → “day dreaming” = absence seizures 36.A nurse is reinforcing teaching with a client who reports right shoulder pain following a laparoscopic cholecystectomy (removal of gallbladder). Which of the following statements should the nurse make? 1) "The pain results from lying in one position too long during surgery." 2) "The pain occurs as a residual pain from cholecystitis." 3) "The pain will dissipate if you ambulate frequently." 4) "The pain is caused from the nitrous dioxide injected into the abdomen." 37.A nurse is checking the suction control chamber of a client's chest tube and notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? 1) Notify the provider. Answer Rationale: The nurse should check for kinks and take other measures before notifying the provider. 2) Verify that the suction regulator is on. 3) Continue to monitor the client because this is an expected finding. 4) Milk the chest tube to dislodge any clots in the tubing that may be occluding it. 38.A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.) 1) Encourage fluid intake. 2) Monitor the puncture site for hematoma. 3) Insert a urinary catheter. 4) Elevate the client’s head of bed. 5) Apply a cervical collar to the client. 39.A nurse is assisting with the care of a client who is postoperative following surgical repair of a fractured mandible. The client’s jaw is wired shut to repair and stabilize the fracture. The nurse should recognize which of the following is the priority action? 1) Relieve the client's pain. 2) Check the client’s pressure points for redness. 3) Provide oral hygiene. 4) Prevent aspiration. Downloaded by: tbosse4 | Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material 40.A nurse is collecting data from a client who has scleroderma (group of rare diseases that involves the hardening and tightening of the skin & connective tissues). Which of the following findings should the nurse expect? 1) A dry raised rash 2) Excessive salivation 3) Periorbital edema 4) Hardened skin 41.A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take? 1) Instruct the client to tilt her head back when she swallows. → tilt chin downwards 2) Place food on the left side of the client's mouth. 3) Add thickener to fluids. → help prevent aspiration (think of dementia patients) 4) Serve food at room temperature. 42.A nurse is caring for a client who has partial-thickness and full-thickness burns of his head, neck, and chest. The nurse should recognize which of the following is the priority risk to the client? 1) Airway obstruction 2) Infection 3) Fluid imbalance 4) Contractures 43.A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis (autoimmune disorder in which antibodies destroy communication between nerves and muscle) and is to start taking neostigmine. Which of the following instructions should the nurse include in the teaching? → think abOut drOOpy eyelid and mOuth; neostigmine - chOlinesterase inhibitOr fOr MG; wOrks by slOwing the breakdOwn of Ach when released frOm nerve endings, meaning mOre is available tO attach tO muscle receptOrs and imprOve strength → AE Of Neostigmine = excessive sweating/saliva, N/V, diarrhea - take early in the mOrning and befOre meals (take at suitable times sO that muscles are strOngest when yOu need tO be the mOst active) 1) Take the medication 45 minutes before eating. → need muscles to be most active 2) Expect diaphoresis as a side effect of the neostigmine. 3) If a medication dose is missed, wait until the next scheduled dose to take the medication. 4) Treat nasal rhinitis with an over-the-counter antihistamine. 44.A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse notes there has not been any urinary output in the last hour. Which of the following actions should the nurse perform first? 1) Notify the provider. 2) Administer a prescribed analgesic. 3) Offer oral fluids. 4) Determine the patency of the tubing. → then notify the provider 45.A nurse is caring for a client scheduled for a bone marrow biopsy. The client expresses fear about the procedure and asks the nurse if the biopsy will hurt. Which of the following responses should the nurse make? Downloaded by: tbosse4 | Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material 1) "You must be very worried about what the biopsy will show." 2) "You'll be asleep for the whole biopsy procedure and won't be aware of what’s happening." 3) "Your provider scheduled this, so she will want to know you still have questions about the procedure." 4) "The biopsy can be uncomfortable, but we will try to keep you as comfortable as possible." 46.A nurse is assisting with planning care for a client who is recovering from a left hemispheric stroke. Which of the following interventions should the nurse include in the plan? 1) Control impulsive behavior. 2) Compensate for left visual field deficits. 3) Re-establish communication. 4) Improve left-side motor function. 47.A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should monitor the client for which of the following manifestations? Manifestations Of DI = extreme thirst, dry skin, cOnstipation, weak muscles, pOlyuria, nocturia → 3 P’s Of diabetes = pOlyuria (excessive urination), pOlyphagia (excessive appetite) and pOlydipsia (increased thirst) 1) Hypotension → d/t weakness, excessive urination: can cause hypotension 2) Polyphagia 3) Hyperglycemia 4) Bradycardia 48.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 49.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? (PAD want to dangle legs; PVD want to elevate) 1) "I will avoid crossing my legs at the knees." 2) "I will use a thermometer to check the temperature of my bath water." Downloaded by: tbosse4 | Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material 3) "I will not go barefoot." 4) "I will wear stockings with elastic tops." → PVD pt. Should not wear compression stockings b/c the pressure could make the ischemic disease worse 50.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. 51.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 → type of new connective tissue that protects the wound surface and fills the wound from the base with new tissue & vasculature 4) An inflammatory response 52.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? (WBC Normal Range = 4,000-10,000) → if lOw WBC cOunt, start w/fOOds high in Vit. C. SalmOn is best fOOd fOr lOw WBC 1) Baked chicken 2) Bagels 3) A factory-sealed box of chocolates 4) Fresh fruit basket → if low WBC, eat foods high in Vit. C (Ex. Fruits) 53.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. → Homan’s sign: dorsiflexion test used for DVT’s 4) Maintain abduction of the right hip. 54.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. → feel for a pulse, then establish an airway, then auscultate 3) Establish an open airway. 4) Auscultate for breath sounds. Downloaded by: tbosse4 | Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material 55.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." 56.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. 57.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. 58.A nurse is reinforcing discharge instructions with a client who has hepatitis A (highly contagious liver infection). Which of the following statements by the client indicates an understanding of the teaching? 1) "I will not eat fried foods."