ATI - Adult Medical Surgical NGN B 2024

ATI - Adult Medical Surgical NGN B 2024 A nurse is providing teaching to a client who is perimenopausal and has a prescription for hormone replacement therapy. For which of the following adverse effects should the nurse instruct the client to notify the provider? -Answer-Calf pain Numbness in the arms Intense headache A nurse is planning care for a client who is postoperative following a laparotomy and has a closed-suction drain. Which of the following actions should the nurse take to manage the drain? -Answer-Compress the drain reservoir after emptying. A nurse is caring for a client who has DKA. Which of the following findings should indicate to the nurse that the client's condition is improving? -Answer-Glucose 272 mg/dL A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr ago. The nurse should identify which of the following findings as an indication of a myocardial infarction (MI)? -Answer-Troponin I 8 ng/mL A nurse is planning a health promotional presentation for a group of African American clients at a community center. Which of the following disorders presents the greatest risk to this group of clients? -Answer-hypertension A nurse is providing education to a client who is at risk for osteoporosis. Which of the following instructions should the nurse include? -Answer-Walk for 30 min four times per week. A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse take? -Answer-Place a pressure bag around the flush solution. A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the following results should the nurse expect? -Answer-PaCO2 56 A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the following instructions should the nurse include? -Answer-Flex the foot every hour when awake. A nurse is planning care for a client who is postoperative following a parathyroidectomy. Which of the following actions should the nurse identify as the priority? -Answer-Place a tracheostomy tray at the bedside. A nurse is evaluating the plan of care for four clients after 2 days of hospitalization. The nurse should identify the need to revise the plan for which of the following clients? - Answer-A client who is postoperative following abdominal surgery and reports feeling that something "popped" when they coughed A nurse is checking the ECG rhythm strip for a client who has a temporary pacemaker. The nurse notes a pacemaker artifact followed by a QRS complex. Which of the following actions should the nurse take? -Answer-Document that depolarization has occurred. A nurse is providing discharge instructions to a client who has active tuberculosis (TB). Which of the following information should the nurse include in the instructions? -Answer- Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures. A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions should the nurse anticipate taking? -Answer-Slow the infusion rate A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the nurse's priority? -Answer-Temperature 38.9° C (102° F) A nurse is caring for a client who has homonymous hemianopsia as a result of a stroke. To reduce the risk of falls when ambulating, the nurse should provide which of the following instructions to the client? -Answer-Scan the environment by turning your head from side to side. A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The client's initial vital signs were heart rate 80/min, blood pressure 130/70 mm Hg, respiratory rate 16/min, and temperature 36° C (96.80 F). Which of the following vital sign changes should alert the nurse that the client might be hemorrhaging? -Answer- Heart rate 110/min A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The client is unable to void on the bedpan. Which of the following actions should the nurse take first? -Answer-Scan the bladder with a portable ultrasound. A nurse is assessing a client who has advanced lung cancer and is receiving palliative care. The client has just undergone thoracentesis. The nurse should expect a reduction in which of the following common manifestations of advanced cancer? -Answer- Dyspnea A nurse is caring for a client who is postoperative. -Answer-Nurses' Notes Client admitted to medical-surgical unit from PACU. Client reports incisional pain as 2 on a scale of 0 to 10. Client appears restless and frequently asks for water. Bilateral lower extremities cool with +1 pedal pulses. Urine output is 40 mL for the past 2 hr. Moderate amount of bright red drainage noted on surgical incision dressing. Vital Signs Temperature 37.6° C (99.7° F) Heart rate 114/min Respiratory rate 22/min Blood pressure 88/54 mm Hg Oxygen saturation 93% on room air Diagnostic Results Hgb 18 g/dL (12 to 16 g/dL) Hct 54% (37% to 47 %) Total WBC count 11,000/mm3 (5,000 to 10,000/mm3) Troponin T 0.04 ng/mL (less than 0.1 ng/mL