Med Surg 2 Final ATI Study Guide(Top QUALITY 2024/2025 EXAM REVIEW) FALL TO SPRING SEMESTER//

Med Surg 2 Final ATI Study Guide A nurse is caring for a client who has chronic venous insufficiency and a prescription for thigh high compression stockings. Which action should the nurse take? a. elevate legs for 10 min, 2-3 times a day while wearing stockings b. apply the stockings in the morning upon awakening and before getting out of bed c. roll the stockings down to the knees to relieve discomfort on the legs d. remove the stockings while out of bed for 1 hour, 4 times a day, to allow the legs to rest - B. Applying the stockings in the morning upon waking up before getting out of bed reduces venous stasis and assists in the venous return of blood to the heart. A nurse is assessing a client who has PAD. Which of the following should the nurse expect? a. edema around ankles and feet b. ulceration around the medial malleoli c. scaling edema of the lower legs with stasis dermatitis d. pallor on elevation of the limbs, and rubber when the limbs are dependent - D. In a client who has PAD, pallor is seen in the extremities when the limbs are elevated, and rubor occurs when they are lowered A nurse is teaching a client who has a new diagnosis of severe peripheral arterial disease. Which should the nurse include? a. Wear tightly fitting insulated socks with shoes when going outside b. elevate both legs above heart when resting c. apply a heating pad to both legs for comfort d. place both legs in dependent position while sleeping - D. Such as hanging off of the bed. This can alleviate swelling and discomfort of the legs A nurse is teaching a client who has a new prescription for clopidogrel. Select all that the nurse should include. a. avoid consumption of grapefruit b. monitor black and tarry stools c. take this when you have pain d. schedule weekly PT test e. Limit food sources containing vit. K while taking this - A, B A nurse is caring for a client who has a DVT and has been taking heparin for a week. Two days ago, the provider also prescribed warfarin. The client asks the nurse about receiving both at the same time. What should the nurse say? a. I will remind your provider that you are already receiving heparin b. your lab findings indicate that 2 anticoagulants are needed c. it takes 3-4 days for the therapeutic effects of warfarin, and then heparin can be discontinued d. only one of these medications are being given to treat your DVT - C. warfarin depresses synthesis of clotting factors but does not have an effect on clotting factors that are present. It takes 3-4 days for the clotting factors that are present to decay and for the therapeutic effects of warfarin to occur. A nurse in an outpatient clinic is assessing a client who reports night sweats and fatigue. He states he had a cough along with nausea and diarrhea. His temperature is 38.1 C orally. The client is afraid he has HIV. Which action should the nurse take? Select all that apply. a. perform a physical assessment b. determine when s/s began c. teach the client about HIV transmission d. draw blood for HIV testing e. obtain a sexual history - a, b, e a nurse is caring for a client who is suspected of having HIV. The nurse should identify that which of the following DX tests and lab values are used to confirm HIV infection? Select all that apply. a. western blot b. Indirect immunofluorescence assay c. CD4+ T-lymphocyte count d. HIV RNA quantification test e. CSF analysis - a, b a nurse is providing teaching for a client who has stage 3 HIV disease. Which of the following statements by the client should indicate to the nurse an understanding of the teaching? a. I will wear gloves while changing the kitty litter b. I will rinse raw fruits with water before eating them c. I will wear a mask when around family members who are ill d. I will cook vegetables before eating them - D, no raw fruits/veggies A nurse is assessing a client for HIV. Which are risk factors? Select all that apply. a. perinatal exposure b. pregnancy c. monogamous sex partner d. older woman adult e. occupational exposure - A, D, E A nurse is providing teaching for a client who has stage 2 HIV and is having difficulty maintaining a normal weight. Which of the following statements by the client should indicate to the nurse an understanding of the teaching? a. I will choose to diet high in fat to help gain weight b. I will be sure to eat 3 large meals a day c. I will drink up to 1 liter of fluid a day d. I will add high-protein foods to my diet - D. high protein and high calorie is the best way to gain weight and maintain health Which instruction should the nurse discuss with the client diagnosed with Raynaud's phenomenon? 1.Explain exacerbations will not occur in the summer. 2. Use nicotine gum to help quit smoking. 3.Wear extra-warm clothing during cold exposure. 4.Avoid prolonged exposure to direct sunlight. - 3. Raynaud's phenomenon is a form of intermittent arteriolar vasoconstriction that results in coldness, pain, and pallor of fingertips or toes; therefore, the client should keep warm to prevent vasoconstriction of the extremities. The nurse is teaching the client with peripheral vascular disease. Which interventions should the nurse discuss with the client? Select all that apply. 1.Wash your feet in antimicrobial soap. 2.Wear comfortable, well-fitting shoes 3.Cut your toenails in an arch. 4.Keep the area between the toes dry. 5.Use a heating pad when feet are cold. - 2.Shoes must be comfortable to prevent blisters or ulcerations of the feet. 4.Moisture between the toes increases fungal growth, leading to skin breakdown. The nurse is caring for clients on a medical floor. Which client will the nurse assess first? 1.The client with an abdominal aortic aneurysm who is constipated. 2.The client on bedrest who ambulated to the bathroom. 3.The client with essential hypertension who has epistaxis and a headache 4.The client with arterial occlusive disease who has a decreased pedal pulse. - 3. A bloody nose and a headache indicate the client is experiencing very high blood pressure and should be assessed first because of a possible myocardial infarction or stroke. The client with peripheral venous disease is scheduled to go to the whirlpool for a dressing change. Which is the nurse's priority intervention? 1.Escort the client to the physical therapy department. 2.Medicate the client 30 minutes before going to the whirlpool. 3.Obtain the sterile dressing supplies for the client 4.Assist the client to the bathroom prior to the treatment. - 2. The client's pain is priority, and the nurse should premedicate prior to treatment. The client is receiving prophylactic low molecular weight heparin. There are no PT/PTT or INR results on the client's chart since admission three (3) days ago. Which action should the nurse implement? 1.Administer the medication as ordered. 2.Notify the health-care provider immediately. 3.Obtain the PT/PTT and INR prior to administering the medication. 4.Hold the medication until the HCP makes rounds. - 1.Subcutaneous heparin will not achieve a therapeutic level because of the short half-life of the medication; therefore, the nurse should administer the medication. The nurse is teaching a class on venous insufficiency. The nurse would identify which condition as the most serious complication of chronic venous insufficiency? 1. Arterial thrombosis. 2. Deep vein thrombosis. 3. Venous ulcerations. 4. Varicose veins. - 3. Venous ulcerations are the most serious complication of chronic venous insufficiency. It is very difficult for these ulcerations to heal, and often clients must be seen in wound care clinics for treatment. Which assessment data would support that the client has a venous stasis ulcer? 1.A superficial pink open area on the medial part of the ankle. 2.A deep pale open area over the top side of the foot. 3.A reddened blistered area on the heel of the foot. 4.A necrotic gangrenous area on the dorsal side of the foot. - 1. The medial part of the ankle usually ulcerates because of edema that leads to stasis, which, in turn, causes the skin to break down. The client with varicose veins asks the nurse, "What caused me to have these?" Which statement by the nurse would be most appropriate? 1."You have incompetent valves in your legs." 2."Your legs have decreased oxygen to the muscle." 3."There is an obstruction in the saphenous vein." 4."Your blood is thick and can't circulate properly." - 1. Varicose veins are irregular, tortuous veins with incompetent valves that do not allow the venous blood to ascend the saphenous vein. The nurse has just received the a.m. shift report. Which client would the nurse assess first? 1. The client with a venous stasis ulcer who is complaining of pain. 2. The client with varicose veins who has dull, aching muscle cramps. 3. The client with arterial occlusive disease who cannot move the foot. 4. The client with deep vein thrombosis who has a positive Homans' sign. - 3. The inability to move the foot means that a severe neurovascular compromise has occurred, and the nurse should assess this client first. The nurse is completing a neurovascular assessment on th