ATI Med Surg Proctored Exam 2024

A nurse is planning care for a client who has a full-thickness burns on the lower extremities. Which of the following interventions should the nurse include? a) Limit visitation time for client's children to 40 minutes per day b) clean the equipment in the client's room once per week c) provide a diet of fresh fruits and vegetable for the client d) apply new gloves when alternating between wound care sites - d) apply new gloves when alternating between wound care sites A nurse is caring for a client who has cancer. The client tells the nurse, "I would prefer to try vitamins and minerals instead of chemotherapy" which of the following responses should the nurse make? a) I have never heard of any holistic treatment that is effective b) you should ask your provider about your plan c) the best way to treat your cancer is chemotherapy d) tell me what you know about chemotherapy - d) tell me what you know about chemotherapy A nurse is planning to teach a client whose provider has prescribed a low purine diet. The nurse should plan to instruct the client that he can include which of the following Foods in his diet (select all that apply) a) Sardines b) Nuts c) Apricots d) liver e) scallops - b) Nuts c) Apricots Nurse is caring for a client following a total knee arthroplasty. The client reports a pain level of 6 on a paint scale of 0 to 10. Which of the following interventions should the nurse take? a) Place pillowsl under the clients knee b) gently massage the area around the clients incision c) apply an ice pack to the clients knee d) perform range of motion exercises to the clients knee - c) apply an ice pack to the clients knee A nurse is caring for a client who has lower extremity fracture and a prescription for crutches. Which of the following client statements indicates that the client is adapting to their role change? a) I will need to have my partner take over shopping for groceries and cooking the meals for us b) Its going to be difficult to tell my parents I can't take them to their appointments anymore c) I feel bad that I have to ask my partner to keep the house clean d) These crutches will make it impossible to care for my child - a) I will need to have my partner take over shopping for groceries and cooking the meals for us A nurse is assessing a client who is preoperative and reports an allergy to bananas. The nurse should recognize that the client is at risk for an allergic cross-reactivity to which of the following substances? a) adhesive tape b) Latex c) Anesthetics d) povidone iodine - b) Latex A nurse on a medical unit is planning care for a group of clients. Which of the following clients should the nurse attend to First? a) A client who has chronic obstructive pulmonary disease in oxygen saturation of 89% b) a client who has left-sided paralysis and slurred speech from a prior stroke c) a client who has thrombocytopenia and reports a nosebleed d) a client who has multiple sclerosis and reports Ataxia and vertigo - c) a client who has thrombocytopenia and reports a nosebleed A nurse is monitoring a client who is receiving two units packed RBC's. Which of the following manifestation indicates a hemolytic transfusion reaction? a) back pain b) Hypertension c) Chills d) bradycardia - a) back pain A nurse is teaching a client who has diabetes mellitus about foot care. Which of the following instruction should the nurse include? a) Use a heating pad to keep your feet warm at night b) wear loose-fitting slippers around the house c) where cotton rather than nylon socks d) wash your face twice per day with antibacterial soap and hot water - c) where cotton rather than nylon socks A nurse is providing teaching to a client who has a deep vein thrombosis (DVT) . Which of the following findings should the nurse identify as a risk factor for the development of the DVTs? a) NSAID use b) hypertension c) oral contraceptive use d) cirrhosis - c) oral contraceptive use A nurse is caring for a client who has a sealed radiation implant. Which of the following actions should the nurse take? a) Remove soiled linens from the room after each change b) Give the dosimeter badge to the oncoming nurse at the end of the shift c) Apply a second pair of gloves before touching the client's implant if it dislodges d) Limit family member visits to 30 min per day - d) Limit family member visits to 30 min per day A nurse is providing teaching to a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication? a) Generalized abdominal pain b) Cloudy effluent c) Increased heart rate d) Fever - d) Fever A nurse is caring for a client who is receiving a blood transfusion. The nurse observes that the client has bounding peripheral pulses, hypertension, and distended jugular veins. The nurse should anticipate administering which of the following prescribed medications? a) Pantoprazole b) Acetaminophen c) Furosemide d) Diphenhydramine - c) Furosemide A nurse is planning care for a client who has upper gastrointestinal bleeding due to a peptic ulcer. Which of the following actions should the nurse plan to take? a) Provide ketorolac for abdominal pain b) Administer nitroprusside IV based on the client's weight c) Insert a large bore nasogastric tube d) Ensure that the client has a 22- gauge iv line in place - c) Insert a large bore nasogastric tube A nurse is caring for a client who has bladder cancer and a WBC count of 900/mm3. Which of the following actions should the nurse take? a) Instruct client to avoid eating raw fruit b) Move the client to a negative pressure room c) Use contact isolation while providing care d) Apply pressure to venipuncture sites for 10 min - a) Instruct client to avoid eating raw fruit A nurse is caring for a patient who has hypotension, cool and clammy skin, tachycardia and tachypnea. Which of the following positions should the nurse place the client? a) Reverse Trendelenburg b) Feet elevated c) Side lying d) High - fowler's - a) Reverse Trendelenburg A nurse is caring for a client who weighs 190 lb and is receiving Total parenteral Nutrition. If the RDA Protein is 0.8g/kg of body weight, how many grams of protein should the client receive daily (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero) - Answer: 69 grams A nurse is planning care for a client who has a central venous access device for intermittent infusions. Which of the following actions should the nurse include in the plan of care? a) Flush a catheter using a 10 mL syringe b) Use clean technique when changing the dressing c) Cleanse the site with Provo dine iodine d) Change the dressing every 24 hours - a) Flush a catheter using a 10 mL syringe A nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the following findings should the nurse report to the provider as a contradiction to receiving heparin? a) Thalassemia b) Rheumatoid arthritis c) COPD d) Thrombocytopenia - d) Thrombocytopenia A nurse is caring for an older adult client who has dementia. Which of the following question should the nurse ask to assess the client's abstract thinking? a) What is meant by saying "don't beat around the bush?" b) What do you understand about your condition? c) Can you count backwards from 100 in intervals of 7? d) Can you state where you were born? - a) What is meant by saying "don't beat around the bush?" A Nurse is completing an assessment of an older adult client and notes reddened areas over the bony prominences, but the client's skin is intact. Which of the following interventions should the nurse include in the plan of care? a) Apply an occlusive dressing b) turn and reposition the client every 4 hours c) support bony prominences with pillows d) massage Tourette in areas three times daily - c) support bony prominences with pillows A nurse is reviewing a cardiac Rhythm strip of a client who has atrial flutter. Which of the following findings should the nurse expect? a) Progressively longer PR durations b) undetectable p waves c) absent PR intervals with ventricular rate of 40 to 60 / minutes d) Sawtooth pattern with atrial rate of 252 400 / minutes - d) Sawtooth pattern with atrial rate of 252 400 / minutes A nurse is caring for a client who is scheduled for an abdominal paracentesis. The nurse should plan to take which of the following actions? a) Administer a stool softener following the procedure b) ask the client to empty his bladder prior to the procedure c) instruct the client to take deep breaths and hold them during the procedure d) assist the client into the left lateral position during the procedure - b) ask the client to empty his bladder prior to the procedure A nurse is caring for a client admitted with a skull fracture. Which of the following assessment findings should be of greatest concern to the nurse? a) Pulse pressure changes from 30 to 20 mmhg b) bilateral pupil diameter changes from 4 to 2 mm c) WBC count changes from 9,000 to 16,000 / mm 3 d) Glasgow Coma Scale score changes from 14 to 9 - d) Glasgow Coma Scale score changes from 14 to 9 A nurse is administering furosemide 80 mg PO twice-daily to a client who has pulmonary edema. Which of the following assessment findings indicates to the nurse that the medication is effective? a) Respiratory rate of 24 / min b) adventitious breath sounds c) weight loss of 1.8 kg (4 lb) in the past 24 hours d) elevation in blood pressure - c) weight loss of 1.8 kg (4 lb) in the past 24 hours A nurse is preparing to administer furosemide to a client who has acute heart failure. Which of the following laboratory results should the nurse identify as a contradiction for receiving the medication? a) Creatinine 0.8 mg / DL b) sodium 136 meq / L c) potassium 3.2 meq / L d) bzun 18 mg / DL - c) potassium 3.2 meq / L A nurse on an oncology unit is caring for a client who is receiving internal radiation therapy. Which of the following actions should the nurse take? a) Place the dosimeter film badge on a client's door b) wear a lead apron when providing client care c) leave the door to the clients room open d) allow visitors to hold the clients hand - b) wear a lead apron when providing client care A nurse is caring for a client who has diabetes mellitus and has been following a treatment plan for 3 months which of the following results should the nurse monitor to determine long-term glycemic control? a) Glycosylated hemoglobin level b) fasting blood glucose level c) oral glucose tolerance test results d) post-prandial blood glucose level - a) Glycosylated hemoglobin level A nurse is providing preoperative teaching for a client who is having left-sided cardiac catheterization. Which of the following information should the nurse include in the teaching? a) You should plan to remain in bed for 18 hours after the procedure b) you will have blood pressure measurement every 5 minutes for the first two hours after the procedure c) You will receive a general anesthetic during the procedure d) you should expect warm sensation after the injection of the contrast dye during the procedure - d) you should expect warm sensation after the injection of the contrast dye during the procedure A nurse is caring for a client who has anemia. Which of the following assessment findings should the nurse anticipate with the client's condition? a) Bradycardia b) Headache c) heat intolerance d) flushed skin color - d) flushed skin color A nurse is teaching a client who has a new prescription for Warfarin about foods that affect the INR. The nurse should include in the teaching that which of the following Foods interact with this medication? a) Kale b) beef stew c) Yogurt d) orange juice - a) Kale A nurse is monitoring an older adult client who has an extrapolation of chronic lymphocytic leukemia. The nurse notes patikayy on the client's skin which of the following actions should the nurse take? a) Determine the client's blood type b) avoid administering IV pain medication c) Implement airborne precautions d) Institute bleeding precautions - d) Institute bleeding precautions A nurse is providing discharge teaching for a client who is receiving treatment for genital herpes. Which of the following statements by the client indicates effectiveness of the teaching? a) I should expect to take my medication for three weeks b) I should apply antibiotic ointment to the lesions c) I should expect my lesions to resolve in 6 weeks d) I should use natural skin condoms during sexual intercourse - b) I should apply antibiotic ointment to the lesions A nurse in an emergency department is preparing a client for emergency surgery. The client's blood alcohol level is 180 mg / DL which of the following action is the nurse's priority? a) Insert an NG Tube b) obtain consent for surgery c) apply anti embolic stockings d) insert an indwelling urinary catheter - a) Insert an NG Tube A nurse is preparing to administer two units of packed rbc's to a client. Which of the following actions should the nurse take? a) Transfuse each unit of blood over five hours b) change the IV tubing after each unit of blood is transfused c) administer the blood through a 22 gauge intravenous catheter d) Prime the tubing with 0.9% sodium chloride - d) Prime the tubing with 0.9% sodium chloride A nurse is caring for a client who has chronic renal failure. The client displays the following ABG results: pH: 7.24 paCO2: 44 mm Hg, paO2 : 84 mmHg, HCO3 : 18 meq/ L base excess - 2 and O2 saturation 95% The nurse should include that the client has which of the following acid-base balances ? a) Metabolic alkalosis b) respiratory acidosis c) respiratory alkalosis d) metabolic acidosis - d) metabolic acidosis A nurse in a provider's office is teaching a client about the self management of GERD which of the following instruction should the nurse include? a) Lie down 30 minutes after each meal b) sleep with the head of your bed elevated 6 inches c) increase your caloric intake by 250 calories per day d) Eat A light meal 1 hour before bedtime - b) sleep with the head of your bed elevated 6 inches A nurse suspects that a client who has diabetes mellitus is experiencing hypoglycemia. Which of the following assessment findings supports this suspicion? a) Cool, clammy skin b) kussmaul respirations c) acetone breath d) increased urine output - a) Cool, clammy skin A nurse is caring for a client who is receiving radiation. The client reports nausea since the therapy was initiated. Which of the following considerations should the nurse include when finding the clients meals? a) Offer hot beverages with meals b) offer a snack prior to radiation therapy c) offer highly seasoned Foods d) offer frequent High carbohydrate meals - d) offer frequent High carbohydrate meals A charge nurse receives a call from the house supervisor requesting room assignments for four new clients. Based on the information diagnosis which of the following clients requires a private room? a) A client service port reports having fever, night sweats, and call for 2 days b) an older adult client who was admitted with aspiration pneumonia c) a client who has diabetes mellitus and is presenting with acute ketoacidosis d) a client who has a compound fracture of the right femur - a) A client service port reports having fever, night sweats, and call for 2 days A nurse in an emergency department is assessing a client who has diabetic ketoacidosis. Which of the following findings should the nurse expect? (select all the apply) a) Tremors b) reports of nausea and vomiting c) Serum glucose 380 mg / DL d) serum pH 7.6 e) fruity smelling breath - b) reports of nausea and vomiting c) Serum glucose 380 mg / DL d) serum pH 7.6 e) fruity smelling breath A nurse is planning a staff education session about hepatitis A. Which of the following information should the nurse include? a) Immunization for Hepatitis A is recommended prior to travel to high-risk areas b) the incubation. Of hepatitis A is 5 to 10 days c) hepatitis A is transmitted is Through Blood to blood exposure d) clients who have Hepatitis A require a broad-spectrum antibiotic - a) Immunization for Hepatitis A is recommended prior to travel to high-risk areas A nurse is caring for a client who has advanced liver disease. Which of the following laboratory results should the nurse monitor when assessing this client? a) Phosphate level b) glucose level c) serum troponin d) Serum ammonia - d) Serum ammonia A nurse is planning care for a client who has status epilepticus. Which of the following interventions is the nurses priority to include? a) Administer phenytoin IV bolus to the client b) provide the client oxygen at 6 L / min using a nasal cannula c) turn the client to the lateral position during seizure activity d) administer diazepam intravenously to the client - c) turn the client to the lateral position during seizure activity A nurse is caring for a client who had a total hip arthroplasty. Which of the following actions should the nurse take to prevent hip dislocation? a) Elevate the knees higher than the hips when sitting b) remove the wedge device when turning c) encourage the client to lean forward when attempting to stand d) place two bed pillows between the legs when in bed - d) place two bed pillows between the legs when in bed A nurse is caring for a client who is receiving Total parenteral Nutrition (TPN) The crane infusion is almost complete and the new solution is not available which of the following actions should the nurse take? a) Infuse dextrose 10% in water b) decrease that tpn infusion rate c) disconnect and flush the IV access line d) administer lactated ringers through the peripheral IV site - a) Infuse dextrose 10% in water A nurse is caring for a client who is 6 hours postoperative following application of an external fixator for a tibial fracture. Which of the following actions should the nurse take? a) Adjust the clamps on the fixator frame b) maintain the affected extremity in a dependent position c) palpate the dorsalis pedis pulse d) rap sterile gauze on the sharp point of the pins - c) palpate the dorsalis pedis pulse A nurse is caring for a client in the emergency department who experienced a full thickness burn injury to the lower torso 1 hour ago. Which of the following findings should the nurse expect? a) Hypotension b) Bradycardia c) decrease respiratory rate d) urinary diuresis - a) Hypotension A nurse is planning care for an older adult client who has Meniere's disease. Which of the following interventions should the nurse include in the plan? a) Perform range of motion exercises to the client's neck every 4 hours b) limited clients fluid intake to 1500 ml / day c) administer aspirin if the client reports a headache d) encourage the client to change position slowly - d) encourage the client to change position slowly A nurse is assessing a client who has a diagnosis on colon cancer which of the following should the nurse expect? a) Statorrhea b) Elevated hemoglobin c) Hematochezia d) Weight gain - c) Hematochezia A nurse is assessing a client admitted with peripheral vascular disease,. Which of the following findings indicates a venous vascular disorder? a) An ulcer at the tip of a toe b) Hair loss distal to the clients calves c) Leg pain at rest d) Edema of the ankle - d) Edema of the ankle A nurse is caring for a client who has a chest tube. The client asks why the fluid in the water -seal chamber rises and falls. Which of the following statements should the nurse make? a) " this means your lung is fully expanded " b) " this indicates a possible leak" c) " suction pressure that is too high causes this" d) " Your breathing pattern causes this" - d) " Your breathing pattern causes this" A community health nurse is reviewing home care instructions with an older adult client who has a new diagnosis of heart failure. Which of the following is the priority topic for the nurse to review with the client? a) Daily sodium restriction b) Daily exercise routine c) Changes in weight d) Fluid intake record - c) Changes in weight A nurse is teaching a client about the use of transcutaneous electrical nerve stimulation (TENS) unit. Which of the following statements should the nurse include? a) "Apply lotion to the site prior to attaching the electrodes" b) " this device requires access to a 220 volt outlet" c) ' this device delivers heat via electrodes that are attached to the effected area" d) "adjust the dial until you feel a 'pins and needles' sensation" - d) "adjust the dial until you feel a 'pins and needles' sensation" A nurse is providing teaching to a client who is postoperative following a total hip arthroplasty. Which of the following statements should the nurse make? a) " use raised toilet seat to maintain your hips above the knees" b) " twist at the waist when standing from a seated position" c) "move your stronger leg first when using a walker" d) " apply a heating pad to the operative hip to decrease pain" - a) " use raised toilet seat to maintain your hips above the knees" A nurse finds a client in bed, unresponsive and breathing. Which of the following action should the nurse take first? a) Establish IV access b) Apply blood pressure cuff c) Palpate for the client's carotid pulse d) Initiate cardiac monitoring for the client - c) Palpate for the client's carotid pulse A nurse is caring who is experiencing a hypertensive crisis. Which of the following actions should the nurse take? a) Initiate IV dopamine infusion b) Perform neurological assessments c) Place the client supine d) Begin an IV bolus of lacted ringer's - b) Perform neurological assessments A nurse is providing discharge teaching about blood sugar monitoring for a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should instruct the client to obtain which of the following supplies? a) Sterile lancets b) Compression stockings c) Hand mirror d) Toenail clippers - c) Hand mirror A nurse is completing discharge teaching who has a peripherally inserted central catheter ( PICC) line in the left arm. Which of the following instructions should the nurse include in the teaching? a) Do not elevate the arm above the level of the heart b) Change the catheter dressing daily c) Use 10- mL syringe to flush line d) Clean the insertion site using 20- mL of hydrogen peroxide - a) Do not elevate the arm above the level of the heart A nurse is preparing naloxone 10 mcg/kg via IV bolus to a client who weighs 220 lbs. the amount available is 0.4 mg/mL. How many mL should the nurse administer? (Round to the nearest tenth) - 2.5ML A nurse is planning the discharge of a client who had an ischemic stroke. The nurse should ensure that the client is discharged with which of the following types of pharmacologic therapy? a) Opioid analgesic b) Anticonvulsant c) anti thrombotic d) diuretic - c) anti thrombotic A nurse is caring for a client who has a new colostomy the nurse notes that the client appears withdrawn and looks away during ostomy care. Which of the following actions should the nurse take? a) Ask the client how they feel about the stoma b) make a referral for the client to see an ostomy nurse c) include the clients partner in stoma care education d) educate the client about expected stoma appearance - a) Ask the client how they feel about the stoma A nurse is preparing to perform ocular irrigation for a client following a chemical Splash to the eye. Which of the following actions should the nurse plan to take first? a) Administer proparacaine eye drops into the affected eye b) places strip of pH paper on to the cul- de- sac of the affected eye c) collect information about the irritant that caused an injury (assess first) d) instill 0.9% sodium chloride solution into the affected eye - c) collect information about the irritant that caused an injury (assess first) A nurse is teaching a client who has AIDS and wishes to continue self care at home despite living alone. Which of the following actions by the nurse demonstrates client advocacy? a) Remind the client of the importance of the medication adherence b) Initiate a referral for the client to a home health agency c) instruct the client to avoid eating raw vegetables d) tell the client to avoid places where there are a large crowds of people - b) Initiate a referral for the client to a home health agency A nurse is assessing a client who has cirrhosis. Which of the following findings is the priority for the nurse to report? a) Alkaline phosphate 125 units /L b) clay-colored stools c) platelets 70,000 / mm3 d) distended abdomen - c) platelets 70,000 / mm3 A home health nurse is providing nutrition education for a client who has trigeminal neuralgia. Which of the following foods should the nurse recommend? a) Graham crackers b) iced coffee c) vanilla pudding d) vegetable soup - c) vanilla pudding A nurse is teaching about food choices to a client who has chronic kidney disease and must limit potassium intake. Which of the following choices should the nurse recommend as containing the least potassium? a) Half cup non-fat yogurt b) two tablespoons of peanut butter c) 1 Cup white rice d) one medium baked potato with skin - c) 1 Cup white rice A nurse is assessing a client following the insertion of a central venous catheter. Which of the following findings indicates a pneumothorax? a) Diminished breath sounds b) Itching over the incision c) Distended neck veins d) Irregular heart rate - a) Diminished breath sounds A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take when performing a close intermittent irrigation? a) Use a 3ml syringe to perform the catheter irrigation b) Clamp the catheter above the specimen port c) Place the client in Trendelenburg position d) Inject the irrigation solution slowly into the catheter - d) Inject the irrigation solution slowly into the catheter A nurse is completing discharge teaching with a client who has a new diagnosis of AIDS. Which of the following statements by the client indicates an understanding of the teaching? a) I will need to take my clothes to the dry cleaners to sterilize them b) I will wipe up areas soiled with body fluids with alcohol and immediately disposed of the trash (should be cleaned with bleach not alcohol) c) I will be sure to wear gloves and wash my hands when I change my cat's litter box d) I will increase the amount of fresh fruits and vegetables I consume - c) I will be sure to wear gloves and wash my hands when I change my cat's litter box A nurse is caring for a client who is post-operative following an endoscopy with moderate (conscious) Sedation. Which of the following assessment findings is the nurse's priority? a) Level of pain b) Gag reflex c) Warmth of extremities d) Temperature - b) Gag reflex Nurse is caring for an older adult client who is suspected of having septicemia. Which of the following actions is the nurse's priority? a) Obtain a history to determine recent injuries b) Obtain a broad-spectrum antibiotic for Rapid Administration c) Obtain a WBC count with differential d) Obtain a blood specimen for culture and sensitivity testing - d) Obtain a blood specimen for culture and sensitivity testing A nurse is caring for a client who has just undergone a total laryngectomy. Which of the following findings is the nurse's priority for immediate intervention? a) Blood-tinged secretions b) Tachypnea c) Fever d) IV infiltration - b) Tachypnea A nurse is admitting a client to the emergency department after a gunshot wound to the abdomen. Which of the following actions should the nurse take to help prevent the onset of acute kidney failure? a) Administer IV fluids to the client b) Insert a urinary catheter c) Initiate beta-blocker therapy d) Prepare the client for an intravenous pyelogram - a) Administer IV fluids to the client A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia. Which of the following assessment finding requires immediate intervention by the nurse? a) a client has 100 ml blood in the closed suction drain b) the client's capillary refill in the left toe is 6 seconds c) the client has an oral temperature of 38.3 C (100.9 Fahrenheit) d) the client reports a pain level of 7 on a scale from 0 to 10 at the operative site - b) the client's capillary refill in the left toe is 6 seconds A nurse is an emergency department is reviewing a client's ECG reading. Which of the following findings should the nurse identify as an indication that the client has a first degree heart block? a) more p waves than QRS complexes b) prolonged PR intervals c) non discernible P waves d) no correlation between P and QRS waves - b) prolonged PR intervals A nurse is reviewing the medication list of a client who is being admitted with diabetes insipidus. Which of the following medication places the client at an increased risk for developing diabetes insipidus? a) Ranitidine b) Atorvastatin c) Propranolol d) lithium - d) lithium A nurse is planning care for a client who has left-sided hemiplegia following a stroke which of the following actions should the nurse include in the plan of care? a) Place a plate guard on the client's meal tray b) position the bedside table on the client's left side c) remind the client to use a cane on his left side while ambulating d) provide the client with a short handled Reacher - a) Place a plate guard on the client's meal tray A nurse is administering potassium chloride via IV infusion to a client who has severe hypokalemia. Which of the following actions should the nurse take? a) Start the infusion at 30 meq /hr b) assess the client for a positive chvostek's sign c) Monitor the client for adequate urine output d) check infusion site at least every 4 hours - a) Start the infusion at 30 meq /hr A nurse in the PACU is caring for a client. Which of the following assessment is the nurses priority? a) Surgical site b) level of consciousness c) respiratory status d) pain level - c) respiratory status A nurse is reviewing the medical record of a client who is scheduled for a CT scan with contrast media. Which of the following medication should the nurse instruct the client to withhold for 48 hours following the procedure? a) Carvedilol b) Furosemide c) Metformin d) Clopidrogel - c) Metformin Nurse is caring for a client who has pancreatitis and has been receiving Total parenteral Nutrition. Which of the following Laboratory test should the nurse monitor for overall nutritional status? a) Creatinine b) Prealbumin c) Lipase d) C-reactive protein - b) Prealbumin A nurse is teaching a client who has endometriosis about the adverse effects of leuprolide. Which of the following manifestations should the nurse include in the teaching? a) Pallor b) Increased appetite c) Bone loss d) Hypoglycemia - c) Bone loss A nurse is providing teaching to a client who is receiving opioids for pain management. Which of the following information should the nurse include in the teaching? a) Monitor urinary output for retention b) avoid taking anti emetics with the medication c) restrict fluid intake If you experience constipation d) itching Indicates you are having an allergic reaction to the medication - a) Monitor urinary output for retention A nurse is providing discharge teaching for a client who has asthma and a new prescription for a metered dose inhaler. Which of the following client statements indicates an understanding of the teaching? a) I should clean the cap of the inhaler once per week b) I should shake the inhaler before I use it c) I Should wait 15 seconds between puffs d) I should inhale the medication quickly - b) I should shake the inhaler before I use it A nurse is assessing a client who has heart failure which of the following client statements should indicate to the nurse that the client needs a referral for cardiac rehabilitation? a) I hate how I feel all the time b) I am too tired to brush my teeth c) I Will Weight myself daily d) I need to start eating a low sodium diet - b) I am too tired to brush my teeth A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. The client reports bladder spasms and the nurse observes decreased urinary output. Which of the following actions should the nurse take? a) Remove the indwelling urinary catheter b) decrease transaction of the catheter c) flush the catheter manually with 0.9% sodium chloride d) administer ibuprofen 400 mg for pain relief - c) flush the catheter manually with 0.9% sodium chloride A nurse is discussing nutrition options with a client who has a new diagnosis of COPD. Which of the following statements should the nurse take? a) Plan to include high protein foods in each of your meals b) increase your intake of vegetables such as broccoli and brussel sprouts c) drink a glass of milk with each meal d) consume three large meals throughout the day - a) Plan to include high protein foods in each of your meals A nurse is teaching a client who has asthma about the use of a peak flow meter. After setting the meter to the zero Base Line, what is the sequence of steps the nurse should instruct the client to take? Rent the Seas move the steps into the box of the right placing them in the selected order of performance. Use all steps) 1. Exhale forcefully and quickly 2. Record the highest of three consecutive readings 3. Stand upright 4. Fill your lungs with a deep breath 5. Seal your lips around the mouth piece - 1. Stand upright 2. Fill your lungs with a deep breath 3. Seal your lips around the mouth piece 4. Exhale forcefully and quickly 5. Record the highest of three consecutive readings A nurse is caring for a client who has bounding pulses, crackles on auscultation, and pink frothy secretions when receiving suction. The nurse should recognize these assessment findings us indicating which of the following? a) Aspiration b) increased cardiac output c) pleural effusion d) fluid volume excess - d) fluid volume excess A nurse in a clinic is providing for preventive teaching to an older client during a Well Visit. The nurse should instruct the client that which of the following immunizations are recommended for healthy adults after age 60 (select all that apply) a) human papillomavirus b) pneumococcal polysaccharide c) Meningococcal d) Influenza e) herpes zoster - a) human papillomavirus d) Influenza e) herpes zoster A nurse is caring for a client who has a traumatic brain injury. The client, who has been quiet and Cooperative, becomes agitated and Restless. Which of the following assessment should the nurse perform first? a) Blood pressure (assess for increased intra cranial pressure) b) blood glucose c) urinary output motor responses - a) Blood pressure (assess for increased intra cranial pressure) A nurse is preparing to administer piperacillin 3.375 grams by intermittent IV bolus every 6 hours. Available is piperacillin 3.375 grams in dextrose 5% in water 100 ml to infuse over 30 minutes. the nurse should set the IV pump to deliver how many ml /hr? (round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) - 675 ml/ hr A nurse is assessing a client who has right-sided heart failure. Which of the following assessment findings should the nurse expect to find? a) Oliguria b) poor skin turgor c) pitting edema d) S3 - S4 Galloping heart sounds - c) pitting edema A nurse is providing discharge teaching to the partner of a client who has a linear incision site following an open cholecystectomy. Which of the following wound care instructions should the nurse include? a. Change the dressing four times per day b. Use sterile gloves when performing the dressing change c. Clean from the incision to the surrounding skin d. Apply tincture of benzoin prior to removing the dressing - c. Clean from the incision to the surrounding skin A nurse is preparing to administer vancomycin IV bolus to a client who has pneumonia. Which of the following clinical manifestations should the nurse instruct the client to monitor for and report? a. Pallor of the extremities b. Taste of metal in the mouth c. Halo of light around objects d. Ringing in the ears - d. Ringing in the ears A nurse is caring for a client who has pancreatitis and has been receiving total parenteral nutrition. Which of the following laboratory tests should the nurse monitor for overall nutritional status? a. Prealbumin b. C reactive protein c. Creatinine d. Lipase - a. Prealbumin A charge nurse is called to a client's room after a staff nurse reports a client has had a wound evisceration. Which of the following actions should the charge nurse take? a. Attempt to reinsert the protruding viscera- DO NOT ATTEMPT TO REINSERT ORGANS b. Obtain bottles of warm, sterile 0.9% sodium chloride solution c. Place the client in left lateral recumbent position- low fowlers hips knees bent d. Apply a firm pressure dressing across the client's abdomen - d. Apply a firm pressure dressing across the client's abdomen A nurse is caring for four clients. Which of the following clients is at risk for developing metabolic alkalosis? a. A client who is receiving continuous gastric suctioning b. A client who has aspiration pneumonia c. A client who is experiencing an opioid overdose- respiratory acidosis. d. A client who has uncontrolled diabetes mellitus - a. A client who is receiving continuous gastric suctioning A nurse is caring for a client who is taking digoxin 0.125 mg PO daily and is at risk for developing digoxin toxicity. The nurse should monitor the client for an imbalance of which of the following electrolytes because it can increase the risk for digoxin toxicity? a. Calcium b. Potassium c. Magnesium d. Phosphatase - b. Potassium A nurse is assessing the abdominal wound of a client who is 3 days postoperative following a colon resection. Which of the following findings should the nurse report to the provider? a. Erythema (redness can be indicative of infection) b. Ecchymotic skin c. Drainage d. Edema - a. Erythema (redness can be indicative of infection) A nurse is completing an admission assessment for a client. The nurse should expect the provider to prescribe which of the following medications for the client? EXHIBIT VITAL SIGNS: Temperature (98.3 F), HR (100/min), RR (20/min), BP (152/94mmHg) a. Atorvastatin b. Allopurinol c. Metoprolol d. levothyroxine - c. Metoprolol A nurse is assessing a client who is near the end of life following a head injury. The client has alternating periods of rapid breathing and apnea. The nurse should document this finding as which of the following respiratory patterns? a. Biot's respirations- quick shallow respirations followed by apnea. b. Hypoventilatory respirations- opoid overdose c. Kussmaul respirations- hyperglycemia d. Cheyne-Stokes respirations- occurs during INCREASED INTRACRANIAL PRESSURE - d. Cheyne-Stokes respirations- occurs during INCREASED INTRACRANIAL PRESSURE A nurse is administering a unit of packed RBCs to a client and notes that there are several small clots floating in the IV bag. Which of the following actions should the nurse take? a. Inject 5,000 units of heparin into the unit of packed RBCs b. Place the unit of packed RBCs in a warming unit for 5 min c. Return the unit of packed RBCs to the blood bank- return that shit d. Dilute the unit of packed RBCs using 50 mL of lactated Ringer's - c. Return the unit of packed RBCs to the blood bank- return that shit A nurse in a provider's office is teaching a client about the self-management of GERD. Which of the following instructions should the nurse include? a. "Eat a light meal 1 hour before bedtime"- avoid eating before bedtime b. "Lie down for 30 minutes after each meal"- CANNOT BE SUPINE c. "Increase your caloric intake by 250 calories per day" d. "Sleep with the head of your bed elevated 6 inches" - d. "Sleep with the head of your bed elevated 6 inches" A nurse is providing teaching to a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication? a. Generalized abdominal pain b. Cloudy effluent c. Fever d. Increased heart rate - c. Fever A nurse is caring for a client who is receiving enteral nutrition. Which of the following interventions by the nurse will prevent aspiration? a. Check the gastric pH following bolus feedings (for verifying placement) b. Place the client in supine position before initiating feedings (No; 30 degree) c. Instruct the client to perform the Valsalva maneuver after feedings (no) d. Measure residual volume prior to bolus feedings - d. Measure residual volume prior to bolus feedings Client has a pressure ulcer. Which indicates wound healing? a. Light yellow exudate (Seropurulent) b. Wound tissue firm to palpation (firm, not healing yet) stage 1. c. Dry brown eschar (dead skin?) d. Dark red granulation tissue - d. Dark red granulation tissue Client, who is 6 hr postoperative following application of an external fixator for a tibial fracture. Which of the following actions should the nurse take? a. Palpate the dorsalis pedis pulse. b. Maintain the affected extremity in a dependent position (ELEVATE) c. Wrap sterile gauze on the shart point of the pins (NOPE 8-12HRS) d. Adjust the clamps on the fixator flame (NEVER, MD DOES THIS) - a. Palpate the dorsalis pedis pulse. A nurse is preparing an in-service presentation about the use of automated external defibrillators (AEDs). Which of the following instructions should the nurse include in the teaching? a. "Perform CPR while the AED is analyzing"-cannot due b/c analysis will be wrong b. "Position the client on a flat surface" c. "Set the AED to 80 joules" (should be 200 joules) d. "Use an AED for a client who has A-fib" (AED is for V-fib & V-tach) - b. "Position the client on a flat surface" Serum sodium level of 120 mEq/L. Which of the followings findings should the nurse expect? a. Hyperreflexia - Decreased DTRs b. Decreased bowel sounds - increased motility, ab cramping, and nausea. c. Confusion d. Increased central venous pressure - c. Confusion Patient taking isoniazid and rifampin, which statement shows they understand? a. "I will be finished with this medication regimen in 3 months" -9 months b. "I should check the whites of my eyes while taking these medications" c. "I should take my mediation with an antacid if it upsets my stomach" (Taking antacid would decrease effectiveness of the medication so it is not advised or SHOULD not take it during treatment) d. "I will no longer be infectious after two consecutive negative sputum specimens" (THREE) - b. "I should check the whites of my eyes while taking these medications" Patient who is in septic shock. Which lab findings indicate the patient is developing "multiple organ dysfunction syndrome"? a. Arterial hypoxemia (low / no oxygen manifestation of MODS) b. Decreased liver enzymes- Increased c. Decreased BUN - Increased d. Hypoglycemia - body response = increase to save body - a. Arterial hypoxemia (low / no oxygen manifestation of MODS) A nurse is reviewing a client's laboratory values and notes a potassium level of 2.8 mEq/L. Which of the following findings should the nurse expect? a. Hyperactive bowel sounds (Hypoactive) b. Increased blood pressure (Hypotension) c. Irregular pulse d. Exaggerated reflexes (CM of Hyperkalemia) - c. Irregular pulse A nurse is caring for a client who is admitted to the medical-surgical unit with a seizure disorder. Which of the following interventions should the nurse include in the plan of care? a. Teach assistive personnel how to apply restraints --> do not attempt to restrain the client b. Keep the side rails in a down position → a) side- rails up with padding to prevent injury c. Keep a padded tongue blade at the client's bedside → do not use padded tongue blades. d. Maintain peripheral IV access. - d. Maintain peripheral IV access. A nurse is collecting a medical history from an older adult client who has hypertension and new prescription of nadolol. Which of the following findings should the nurse report to the provider? a. cataracts b. GERD c. Asthma d. Hypothyroidism - c. Asthma 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? 1. Start the therapy within 8 hrs. (within 6 hrs.) 2. Insert an indwelling urinary catheter after therapy begins 3.Monitor blood pressure every 30 minutes during infusion. 4.Elevate the head of the bed between 25 and 30 degrees - 4.Elevate the head of the bed between 25 and 30 degrees 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? 1. Place hands on the upper abdomen during inhalation. 2. Exhale slowly through pursed lips. 3. Hold breath about 3 to 5 seconds before exhaling. (ATI page 138) 4. Position the mouthpiece 2.5 cm (1 in) from the mouth - 3.Hold breath about 3 to 5 seconds before exhaling. (ATI page 138) 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? 1. Heart rate 90/mm 2. Hgb 8.2 g/dL 3. Gastric ph of 3.0 4. Absent bowel sounds - 4.Absent bowel sounds A nurse is caring for a client who has diabetes insipidus. Which of the following medications should the nurse plan to administer? 1.Regular Insulin 2.Furosemide 3.Desmopressin 4.Lithium Carbonate - 3.Desmopressin