ATI RN Adult Medical Surgical Practice H 2024 with questions and correct answers.

ATI RN Adult Medical Surgical Practice H 2024 A nurse is caring for a client who has a leg cast and is returning to demonstrate on the proper use of crutches while climbing stairs. Identify the sequence the client should follow when demonstrating crutch use. • Brings the crutches and the affected leg up to the stair • Places body weight on the crutches • Shifts weight from the crutches to the unaffected leg • Advances the unaffected leg onto the stair ________________________________________ A nurse is caring for a client who has hypothyroidism. Which of the following manifestations should the nurse expect? • Constipation • Insomnia • Tachycardia • Diaphoresis • Constipation Rationale: a client who has hypothyroidism can experience constipation due to the decrease in the client's metabolism, resulting in slow motility of the gi tract. The nurse should instruct the client to increase fiber and fluid intake to reduce the risk for constipation. ________________________________________ A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following nonpharmacological interventions should the nurse suggest to the client to reduce pain? • Increase intake of foods containing calcium • Alternate application of heat and cold to the affected joints • Keep the affected extremities elevated • Limit movement of the affected joints • Alternate application of heat and cold to the affected joints Rationale: the nurse should instruct the client to alternate heat and cold applications to decrease joint inflammation and pain. The application of cold can relieve joint swelling, and the application of heat can decrease joint stiffness and pain. ________________________________________ 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? • Administer an antihistamine • Slow the infusion rate • Give the client a corticosteroid • Elevate the client's lower extremities • Slow the infusion rate Rationale: dyspnea, restlessness, and the onset of crackles during a blood transfusion are manifestations of circulatory overload. The nurse should slow or stop the infusion to improve the client's ability to breathe, place the client in an upright position, and notify the provider. The provider might prescribe a diuretic to alleviate the fluid overload. ________________________________________ A nurse in the emergency department is assessing a client who has a detached retina. Which of the following should the nurse expect the client to report? • "it's like a curtain closed over my eye." • "this sharp pain in my eye started 2 hours ago." • "i've been having more and more difficulty seeing over the last few weeks." • "i seem to have more problems seeing different colors." • "it's like a curtain closed over my eye." Rationale: a retinal detachment is the separation of the retina from the epithelium. It can occur because of trauma, cataract surgery, retinopathy, or uveitis. Clients who have retinal detachment typically report the sensation of a curtain being pulled over part of the visual field. ________________________________________ A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate this risk, which of the following dietary alterations should the nurse recommend? • Add full-fat yogurt to the diet • Add cabbage to the diet • Replace butter with coconut oil • Replace shellfish with red meat • Add cabbage to the diet Rationale: to help reduce the risk for colorectal cancer, the client should consume a diet that is high in fiber, low in fat, and low in refined carbohydrates. Brassica vegetables, such as cabbage, cauliflower, and broccoli, are high in fiber. ________________________________________ A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take? (select all that apply.) • Ask the client to rate their pain on a 0 to 10 pain scale • Instruct the client to splint the abdomen with a pillow for coughing • Plan to ambulate the client as soon as possible • Apply oxygen via a face mask • Report urinary output to the provider • Instruct the client to splint the abdomen with a pillow for coughing Rationale: it is important for the client to turn, cough, and deep breathe to reduce the risk for respiratory complications. The nurse should instruct the client to splint the incision while performing these actions to reduce the risk of complications to the surgical incision. • Plan to ambulate the client as soon as possible Rationale: the nurse should plan to ambulate the client as soon as possible to promote ventilation and decrease the risk of thrombosis. • Report urinary output to the provider Rationale: the client should produce at least 30 ml of urine per hour. Therefore, the nurse should report this finding to the provider. • Ask the client to rate their pain on a 0 to 10 pain scale Rationale: the nurse should have the client rate their pain prior to and following the administration of pain medication to evaluate its effectiveness. ________________________________________