med surg ati proctored exam (Sent)-
latest update
A nurse is preparing to administer a unit of packed RBCs to a client who is anemic.
Identify the sequence of steps the nurse should follow.
e. Remain with the client for the first 15 to 30 min of the infusion
a. Obtain venous access using 19-gauge needle
c. Verify blood compatibility with another nurse
d. Initiate transfusion of the unit of packed RBCs
b. Obtain the unit of packed RBCs from blood bank - CORRECT ANSWERS-a. Obtain
venous access using 19-gauge needle
b. Obtain the unit of packed RBCs from blood bank
c. Verify blood compatibility with another nurse
d. Initiate transfusion of the unit of packed RBCs
e. Remain with the client for the first 15 to 30 min of the infusion
A nurse is preparing a teaching plan for a client who has mucositis related to
chemotherapy treatment. Which of the following instructions should the nurse include?
a. "rinse your mouth with hydrogen peroxide"
b. "brush your teeth for 60 seconds twice daily"
c. "wear your dentures only during meals"
d. "floss your teeth following each meals" - CORRECT ANSWERS-d. "floss your teeth
following each meals"
A critical care nurse is assessing a client who has severe head injury. In response to
painful stimuli, the client does not open her eyes, displays decerebrate posturing, and
makes incomprehensible sounds. Which of the following Glasgow Coma Scale scores
should the nurse assign the client?
a. 5
b. 2
c. 13
d. 10 - CORRECT ANSWERS-a. 5
A nurse is providing discharge teaching to a client who has heart failure and instructs
him to limit sodium intake to 2 g per day. Which of the following statements by the client
indicates an understanding of the teaching?
a. "I can season my foods with garlic and onion salts"
b. "I can have mayonnaise on my sandwiches"
c. "I can have a frozen fruit juice bar for dessert"
d. "I can drink vegetable juice with a meal" - CORRECT ANSWERS-c. "I can have a
frozen fruit juice bar for dessert"
A nurse is preparing to perform ocular irrigation for a client following chemical splash to
the eye. Which of the following actions should the nurse plan to take first?
,a. Instill 0.9% sodium chloride solution into the affected eye
b. Administer proparacaine eyedrops into the affected eye
c. Collect information about the irritant that caused the injury - CORRECT ANSWERS-c.
Collect information about the irritant that caused the injury
A nurse in an emergency department is preparing to perform an ocular irrigation for a
client. Which of the following actions should the nurse plan to take?
a. Assess the client's visual acuity prior to irrigation
b. Have the client turn their head toward the unaffected eye
c. Hold the irrigator syringe 3.81 cm (1.5 in) above the eye
d. Perform the irrigation with sterile water for irrigation - CORRECT ANSWERS-d.
Perform the irrigation with sterile water for irrigation
A nurse is preparing to administer lactated ringer's via continuous IV infusion at 200
ml/hr. The IV tubing has a drop factor of 10 drops/ml. How many gtt/min should the
nurse set the IV pump to administer? Round to near whole number - CORRECT
ANSWERS-33 gtt/min
A nurse is providing discharge teaching to a client who has a new prescription for
sublingual nitroglycerin. Which of the following client statements indicates an
understanding of the teaching?
a. I can keep my medications for 1 year before replacing it
b. I should lie down when I take this medication
c. I should discontinue this medication if I develop a headache
d. I can take up to five tablets in 15 minutes before seeking medical attention -
CORRECT ANSWERS-b. I should lie down when I take this medication
A nurse is providing discharge teaching to an older adult client following a left total hip
arthroplasty. Which of the following instructions should the nurse include in the
teaching?
a. Clean the incision daily with hydrogen peroxide
b. You can cross your legs the ankles when sitting down
c. You should use an incentive spirometer every 8 hours
d. Install a raised toilet seat in your bathroom - CORRECT ANSWERS-d. Install a raised
toilet seat in your bathroom
A nurse is planning care for a client following a cardiac catheterization. Which of the
following actions should the nurse take?
a. Keep the client on bed rest for 24 hours
b. Limit the client's fluid intake to 1 l per day
c. Maintain the client's affected extremity in extension
d. Change the client's dressing every 8 hour - CORRECT ANSWERS-c. Maintain the
client's affected extremity in extension
, A nurse is caring for a client who has a 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. These crutches will make it impossible to care for my child
c. I feel bad that I have to ask my partner to keep the house clean
d. Its going to be difficult to tell my parents I cant take them to their appointments
anymore - CORRECT ANSWERS-a. I will need to have my partner take over shopping
for groceries and cooking the meals for us
A nurse is caring for a client who has gastroenteritis. Which of the following assessment
findings should the nurse recognize as an indication that the client is experiencing
dehydration?
a. Pitting, dependent edema
b. Distended jugular veins
c. Increased BP
d. Decreased BP - CORRECT ANSWERS-d. Decreased BP
A nurse is caring for a client who has a contusion of the brainstem and reports thirst.
The client's urinary output was 4,000 ml over the past 24 hour. The nurse should
anticipate a prescription for which of the following IV medication?
a. Desmopressin
b. Epinephrine
c. Furosemide
d. Nitroprusside - CORRECT ANSWERS-a. Desmopressin
A nurse in a clinic receives a phone call from a client who recently started therapy with
an ACE inhibitor and reports a nagging dry cough. Which of the following responses by
the nurse is appropriate?
a. "your cough may require that you stop or change your medication"
b. "Increasing your daily fluid intake may eliminate your cough"
c. "sucking on lozenge may reduce the frequency of your cough"
d. You cough should go away in time" - CORRECT ANSWERS-a. "your cough may
require that you stop or change your medication"
A nurse is taking an admission history from a client who reports Raynaud's disease.
Which of the following assessment findings should the nurse identify as a potential
trigger for exacerbations
of Raynaud's?
a. Eating a strict vegetarian diet
b. A history of herpes zoster
c. Taking amiodipine for hypertension
d. Using a nicotine transdermal patch - CORRECT ANSWERS-d. Using a nicotine
transdermal patch
latest update
A nurse is preparing to administer a unit of packed RBCs to a client who is anemic.
Identify the sequence of steps the nurse should follow.
e. Remain with the client for the first 15 to 30 min of the infusion
a. Obtain venous access using 19-gauge needle
c. Verify blood compatibility with another nurse
d. Initiate transfusion of the unit of packed RBCs
b. Obtain the unit of packed RBCs from blood bank - CORRECT ANSWERS-a. Obtain
venous access using 19-gauge needle
b. Obtain the unit of packed RBCs from blood bank
c. Verify blood compatibility with another nurse
d. Initiate transfusion of the unit of packed RBCs
e. Remain with the client for the first 15 to 30 min of the infusion
A nurse is preparing a teaching plan for a client who has mucositis related to
chemotherapy treatment. Which of the following instructions should the nurse include?
a. "rinse your mouth with hydrogen peroxide"
b. "brush your teeth for 60 seconds twice daily"
c. "wear your dentures only during meals"
d. "floss your teeth following each meals" - CORRECT ANSWERS-d. "floss your teeth
following each meals"
A critical care nurse is assessing a client who has severe head injury. In response to
painful stimuli, the client does not open her eyes, displays decerebrate posturing, and
makes incomprehensible sounds. Which of the following Glasgow Coma Scale scores
should the nurse assign the client?
a. 5
b. 2
c. 13
d. 10 - CORRECT ANSWERS-a. 5
A nurse is providing discharge teaching to a client who has heart failure and instructs
him to limit sodium intake to 2 g per day. Which of the following statements by the client
indicates an understanding of the teaching?
a. "I can season my foods with garlic and onion salts"
b. "I can have mayonnaise on my sandwiches"
c. "I can have a frozen fruit juice bar for dessert"
d. "I can drink vegetable juice with a meal" - CORRECT ANSWERS-c. "I can have a
frozen fruit juice bar for dessert"
A nurse is preparing to perform ocular irrigation for a client following chemical splash to
the eye. Which of the following actions should the nurse plan to take first?
,a. Instill 0.9% sodium chloride solution into the affected eye
b. Administer proparacaine eyedrops into the affected eye
c. Collect information about the irritant that caused the injury - CORRECT ANSWERS-c.
Collect information about the irritant that caused the injury
A nurse in an emergency department is preparing to perform an ocular irrigation for a
client. Which of the following actions should the nurse plan to take?
a. Assess the client's visual acuity prior to irrigation
b. Have the client turn their head toward the unaffected eye
c. Hold the irrigator syringe 3.81 cm (1.5 in) above the eye
d. Perform the irrigation with sterile water for irrigation - CORRECT ANSWERS-d.
Perform the irrigation with sterile water for irrigation
A nurse is preparing to administer lactated ringer's via continuous IV infusion at 200
ml/hr. The IV tubing has a drop factor of 10 drops/ml. How many gtt/min should the
nurse set the IV pump to administer? Round to near whole number - CORRECT
ANSWERS-33 gtt/min
A nurse is providing discharge teaching to a client who has a new prescription for
sublingual nitroglycerin. Which of the following client statements indicates an
understanding of the teaching?
a. I can keep my medications for 1 year before replacing it
b. I should lie down when I take this medication
c. I should discontinue this medication if I develop a headache
d. I can take up to five tablets in 15 minutes before seeking medical attention -
CORRECT ANSWERS-b. I should lie down when I take this medication
A nurse is providing discharge teaching to an older adult client following a left total hip
arthroplasty. Which of the following instructions should the nurse include in the
teaching?
a. Clean the incision daily with hydrogen peroxide
b. You can cross your legs the ankles when sitting down
c. You should use an incentive spirometer every 8 hours
d. Install a raised toilet seat in your bathroom - CORRECT ANSWERS-d. Install a raised
toilet seat in your bathroom
A nurse is planning care for a client following a cardiac catheterization. Which of the
following actions should the nurse take?
a. Keep the client on bed rest for 24 hours
b. Limit the client's fluid intake to 1 l per day
c. Maintain the client's affected extremity in extension
d. Change the client's dressing every 8 hour - CORRECT ANSWERS-c. Maintain the
client's affected extremity in extension
, A nurse is caring for a client who has a 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. These crutches will make it impossible to care for my child
c. I feel bad that I have to ask my partner to keep the house clean
d. Its going to be difficult to tell my parents I cant take them to their appointments
anymore - CORRECT ANSWERS-a. I will need to have my partner take over shopping
for groceries and cooking the meals for us
A nurse is caring for a client who has gastroenteritis. Which of the following assessment
findings should the nurse recognize as an indication that the client is experiencing
dehydration?
a. Pitting, dependent edema
b. Distended jugular veins
c. Increased BP
d. Decreased BP - CORRECT ANSWERS-d. Decreased BP
A nurse is caring for a client who has a contusion of the brainstem and reports thirst.
The client's urinary output was 4,000 ml over the past 24 hour. The nurse should
anticipate a prescription for which of the following IV medication?
a. Desmopressin
b. Epinephrine
c. Furosemide
d. Nitroprusside - CORRECT ANSWERS-a. Desmopressin
A nurse in a clinic receives a phone call from a client who recently started therapy with
an ACE inhibitor and reports a nagging dry cough. Which of the following responses by
the nurse is appropriate?
a. "your cough may require that you stop or change your medication"
b. "Increasing your daily fluid intake may eliminate your cough"
c. "sucking on lozenge may reduce the frequency of your cough"
d. You cough should go away in time" - CORRECT ANSWERS-a. "your cough may
require that you stop or change your medication"
A nurse is taking an admission history from a client who reports Raynaud's disease.
Which of the following assessment findings should the nurse identify as a potential
trigger for exacerbations
of Raynaud's?
a. Eating a strict vegetarian diet
b. A history of herpes zoster
c. Taking amiodipine for hypertension
d. Using a nicotine transdermal patch - CORRECT ANSWERS-d. Using a nicotine
transdermal patch
