ATI Med Surg Proctored Exam 4
j j j j j j
j
An jolder jadult jis jbrought jto jan jemergency jdepartment jby ja jfamily jmember. jWhich
jof jthe jfollowing jassessment jfindings jshould jcause jthe jnurse jto jsuspect jthat jthe
jclient jhas jhypertonic jdehydration? j- jUrine jSpecific jgravity j1.045 j j
j
A jurine jspecific jgravity jgreater jthan j1.030 jindicates ja jdecrease jin jurine jvolume jand
j
j
an jincrease jin josmolarity, jwhich jis ja jmanifestation jof jhypertonic jdehydration.
j
A jnurse jin ja jcommunity jclinic jis jcaring jfor ja jclient jwho jreports jan jincrease jin jthe
jfrequency jof jmigraine jheadaches. jTo jhelp jreduce jthe jrisk jfor jmigraine jheadaches,
jwhich jof jthe jfollowing jfoods jshould jthe jnurse jrecommend jthe jclient javoid? j- jAged
jcheese j
j
Foods jthat jcontain jtyramine, jsuch jas jaged jcheese jand jsausage, jcan jtrigger
j
j
migraine jheadaches.
j
A jnurse jis jplanning jteaching jfor ja jclient jwho jhas jbladder jcancer jand jis jto jundergo
ja jcutaneous jdiversion jprocedure jto jestablish ja jureterostomy. jWhich jof jthe jfollowing
jstatements jshould jthe jnurse jinclude jin jthe jteaching? j- j"You jshould jcut jthe jopening
jof jthe jskin jbarrier jone-eight jinch jwider jthan jthe jstoma." j j
j
The jclient jshould jcut jthe jopening jof jthe jskin jbarrier j0.3 jcm j(1/8in) jwider jthan
jthe j
j
stoma jto jminimize jirritation jof jthe jskin jfrom jexposure jto jurine.
j
A jnurse jis jproviding jteaching jto ja jclient jwho jhas jhypothyroidism jand jis jreceiving
jlevothyroxine. jThe jnurse jshould jinstruct jthe jclient jthat jwhich jof jthe jfollowing
jsupplements jcan jinterfere jwith jthe jeffectiveness jof jthe jmedication? j- jCalcium j
j
Calcium jlimits jthe jdevelopment jof josteoporosis jin jclients jwho jare jpostmenopausal
jand jworks jas jan jantacid. jCalcium jsupplements jcan jinterfere jwith jthe jmetabolism jof
ja jnumber jof jmedications, jincluding jlevothyroxine. jThe jnurse jshould jinstruct jthe
jclient jto javoid jtaking jcalcium jwithin j4 jhr jof jlevothyroxine jadministration. j
j
A jnurse jis jconducting jan jadmission jhistory jfor ja jclient jwho jis jto jundergo ja jCT jscan
j
j
with jan jIV jcontrast jagent. jThe jnurse jshould jidentify jthat jwhich jof jthe jfollowing
j j
findings jrequires jfurther jassessment? j- jHistory jof jasthma
j
A jclient jwho jhas ja jhistory jof jasthma jhas ja jgreater jrisk jof jreacting jto jthe jcontrast
jdye jused jduring jthe jprocedure. jOther jconditions jthat jcan jresult jin ja jreaction jto
jcontrast jmedia jinclude jallergies jto jfoods, jsuch jas jshellfish, jeggs, jmilk, jand
jchocolate. j
j
A jnurse jin jan jICU jis jassessing ja jclient jwho jhas ja jtraumatic jbrain jinjury. jWhich jof
jthe j
j
following jfindings jshould jthe jnurse jidentify jas ja jcomponent jof jCushing's jtriad?
j-
j
Bradycardia
j
j
,A jclient jwho jhas jincreased jintracranial jpressure jfrom ja jtraumatic jbrain jinjury jcan
j
j
develop jbradycardia, jwhich jis jone jcomponent jof jCushing's jtriad. jThe jother
components jof jCushing's jtriad jare jsevere jhypertension jand ja jwidened jpulse
j
j
pressure.
j
A jnurse jis jplanning jto jirrigate jand jdress ja jclean, jgranulating jwound jfor ja jclient jwho
j
has ja jpressure jinjury. jWhich jof jthe jfollowing jactions jshould jthe jnurse jtake? j- jUse
ja j
j
30-mL jsyringe
j
j
The jnurse jshould juse ja j30-mL jto j60-mL jsyringe jwith jan j18- jor j19- jgauge jcatheter
jto j
deliver jthe jideal jpressure jof j8 jpounds jper jsquare jinch j(psi) jwhen jirrigating ja jwound.
j
To jmaintain jhealthy jgranulation jtissue, jthe jwound jirrigation jshould jbe jdelivered jat
j
between j4 jand j15 jpsi.
j
A jnurse jin jan jemergency jdepartment jis jreviewing jthe jprovider's jprescriptions jfor
ja j
client jwho jsustained ja jrattlesnake jbite jto jthe jlower jleg. jWhich jof jthe jfollowing
j
prescriptions jshould jthe jexpect? j- jAdminister jan jopioid janalgesic jto jthe jclient. j j
j
The jnurse jshould jexpect ja jprescription jfor jan jopioid janalgesic jto jpromote jcomfort
j
j
following ja jrattlesnake jbite.
j
A jnurse jis jreviewing jthe jhealth jrecord jof ja jclient jwho jis jscheduled jfor jallergy jskin
jtesting. jThe jnurse jshould jpostpone jthe jtesting jand jreport jto jthe jprovider jwhich jof
jthe jfollowing jfindings? j(Click jon jthe j"Exhibit" jbutton jfor jadditional jinformation jabout
jthe jclient). j- jCurrent jmedications j j
j
The jnurse jshould jreview jthe jclient's jmedication jrecord jand jidentify jmedications,
jincluding jACE jinhibitors, jbeta jblockers, jtheophylline, jnifedipine, jand
jglucocorticoids, jsuch jas jprednisone, jthat jcan jalter jthe jallergy jskin jtest jresults.
jThese jmedications jcan jdiminish jthe jclient's jreaction jto jthe jallergens. jThe jnurse
jshould jnotify jthe jprovider jand jinstruct jthe jclient jto jdiscontinue jprednisone jfor j2
jweeks jbefore jallergy jskin jtesting. j
j
A jnurse jis ja jcaring jfor ja jclient jwho jis jon jbed jrest jand jhas ja jnew jprescription jfor
jenoxaparin jsubcutaneous. jWhich jof jthe jfollowing jactions jshould jthe jnurse jtake? j-
jInject jthe jmedication jinto jthe janterolateral jabdominal jwall. j j
j
j
The jnurse jshould jinject jthe jmedication jinto jthe janterolateral jor jposterolateral
abdominal jwall jto jenhance jmedication jabsorption jand jprevent jhematoma jformation.
j
j
A jnurse jis jcaring jfor ja jclient jwho jhas ja jstage jIII jpressure jinjury. jWhich jif
jthe
following jfindings jcontribute jto jdelayed jwound jhealing? j- jUrine joutput j25 jmL/hr
j
j
Urinary joutput jreflects jfluid jstatus. jInadequate jurine joutput jcan jindicate jdehydration,
j
, j
which jcan jdelay jwound jhealing.
j
A jnurse jis jcaring jfor ja jclient jwho jhas ja jnew jprescription jfor jtotal jparenteral jnutrition
j(TPN). jThe jclient jis jto jreceive j2,000 jkcal jper jday. jThe jTPN jsolution jhas j500kcal/L.
jThe jIV jpump jshould jbe jset jat jhow jmany jmL/hr? j(Rounding jto jthe jnearest jwhole
jnumber.) j- j167 jmL/hr j
j
A jnurse jis jteaching ja jclient jwho jhas ja jfamily jhistory jof jcolorectal jcancer. jTo jhelp
j
j
mitigate jthis jrisk, jwhich jof jthe jfollowing jdietary jalterations jshould jthe jnurse
j j
recommend? j- jAdd jcabbage jto jthe jdiet.
j
To jhelp jreduce jthe jrisk jfor jcolorectal jcancer, jthe jclient jshould jconsume ja jdiet jthat
jis jhigh jin jfiber, jlow jin jfat, jand jlow jin jrefined jcarbohydrates. jBrassica jvegetables
jsuch jas jcabbage, jcauliflower, jand jbroccoli, jare jhigh jin jfiber. j
j
A jnurse jis jcaring jfor ja jclient jwho jhas ja jprescription jfor jsilver jsulfadiazine jcream jto
jbe japplied jto jher jburn jwounds. jThe jnurse jshould jevaluate jthe jclient jfor jwhich jof
jthe jfollowing jlaboratory jfindings? j- jLeukopenia j j
j
Transient jleukopenia jis jan jadverse jeffect jof jsilver jsulfadiazine. j
j
A jnurse jis jteaching ja jclient jwith jsystemic jerythematosus jwho jhas ja jnew jprescription
j
j
for jprednisone. jThe jnurse jshould jinstruct jthe jclient jto jmonitor jfor jwhich jof jthe
j j
following jadverse jeffects jof jthis jmedication? j- jInfection
j
The jnurse jshould jinstruct jthe jclient jto javoid jcontact jwith jpeople jwho jare jill jand
jmonitor jfor jmanifestations jof jan jinfection jsuch jas ja jfever jor ja jsore jthroat. j
Prednisone jcan jsuppress jthe jclient's jimmune jresponse jand jmask jthe
jmanifestations jof jan jinfection. j
j
A jnurse jis jproviding jpreoperative jteaching jto ja jclient jwho jwill jundergo ja jtotal
jlaryngectomy. jWhich jof jthe jfollowing jstatements jindicates jthat jthe jclient
junderstands jthe jimpact jof jthe jsurgery? j- j"I junderstand jthat jI jwill jhave ja jpermanent
jtracheostomy jafter jthe jsurgery." j j
j
With ja jpartial jlaryngectomy, jthe jtracheostomy jis jtemporary. jThis jclient jwill jhave
ja j
j
total jlaryngectomy, jso jthe jtracheostomy jwill jbe jpermanent.
j
A jnurse jis jassessing ja jclient jwho jhas jsystemic jscleroderma. jWhich jof jthe jfollowing
j
j
findings jshould jthe jnurse jexpect? j- jFinger jcontractures
j
Scleroderma jis ja jchronic jdisease jthat jcan jcause jthickening, jhardening, jor
jtightening jof jthe jskin, jblood jvessels, jand jinternal jorgans. jThere jare j2 jtypes jof
jscleroderma: jlocalized jscleroderma, jwhich jmainly jaffects jthe jskin, jand jsystemic
jscleroderma, jwhich jcan jaffect jinternal jorgans. jManifestations jinclude jskin jchanges,
jRaynaud's jphenomenon, jarthritis, jmuscle jweakness, jand jdry jmucous jmembranes.
jWith jscleroderma jthe jbody jproduces jand jdeposits jtoo jmuch jcollagen, jcausing
jthickening jand jhardening. jIn jaddition jto jthe jclient's jskin jand jsubcutaneous jtissues
jbecoming jincreasingly jhard jand jrigid, jthe jextremities jstiffen jand jlose jmobility.
jContractures jdevelop jwith jadvanced jsystemic jscleroderma junless jclients jfollow ja
jregimen jof jrange-of-motion jand jmuscle-strengthening jexercises. j
j j j j j j
j
An jolder jadult jis jbrought jto jan jemergency jdepartment jby ja jfamily jmember. jWhich
jof jthe jfollowing jassessment jfindings jshould jcause jthe jnurse jto jsuspect jthat jthe
jclient jhas jhypertonic jdehydration? j- jUrine jSpecific jgravity j1.045 j j
j
A jurine jspecific jgravity jgreater jthan j1.030 jindicates ja jdecrease jin jurine jvolume jand
j
j
an jincrease jin josmolarity, jwhich jis ja jmanifestation jof jhypertonic jdehydration.
j
A jnurse jin ja jcommunity jclinic jis jcaring jfor ja jclient jwho jreports jan jincrease jin jthe
jfrequency jof jmigraine jheadaches. jTo jhelp jreduce jthe jrisk jfor jmigraine jheadaches,
jwhich jof jthe jfollowing jfoods jshould jthe jnurse jrecommend jthe jclient javoid? j- jAged
jcheese j
j
Foods jthat jcontain jtyramine, jsuch jas jaged jcheese jand jsausage, jcan jtrigger
j
j
migraine jheadaches.
j
A jnurse jis jplanning jteaching jfor ja jclient jwho jhas jbladder jcancer jand jis jto jundergo
ja jcutaneous jdiversion jprocedure jto jestablish ja jureterostomy. jWhich jof jthe jfollowing
jstatements jshould jthe jnurse jinclude jin jthe jteaching? j- j"You jshould jcut jthe jopening
jof jthe jskin jbarrier jone-eight jinch jwider jthan jthe jstoma." j j
j
The jclient jshould jcut jthe jopening jof jthe jskin jbarrier j0.3 jcm j(1/8in) jwider jthan
jthe j
j
stoma jto jminimize jirritation jof jthe jskin jfrom jexposure jto jurine.
j
A jnurse jis jproviding jteaching jto ja jclient jwho jhas jhypothyroidism jand jis jreceiving
jlevothyroxine. jThe jnurse jshould jinstruct jthe jclient jthat jwhich jof jthe jfollowing
jsupplements jcan jinterfere jwith jthe jeffectiveness jof jthe jmedication? j- jCalcium j
j
Calcium jlimits jthe jdevelopment jof josteoporosis jin jclients jwho jare jpostmenopausal
jand jworks jas jan jantacid. jCalcium jsupplements jcan jinterfere jwith jthe jmetabolism jof
ja jnumber jof jmedications, jincluding jlevothyroxine. jThe jnurse jshould jinstruct jthe
jclient jto javoid jtaking jcalcium jwithin j4 jhr jof jlevothyroxine jadministration. j
j
A jnurse jis jconducting jan jadmission jhistory jfor ja jclient jwho jis jto jundergo ja jCT jscan
j
j
with jan jIV jcontrast jagent. jThe jnurse jshould jidentify jthat jwhich jof jthe jfollowing
j j
findings jrequires jfurther jassessment? j- jHistory jof jasthma
j
A jclient jwho jhas ja jhistory jof jasthma jhas ja jgreater jrisk jof jreacting jto jthe jcontrast
jdye jused jduring jthe jprocedure. jOther jconditions jthat jcan jresult jin ja jreaction jto
jcontrast jmedia jinclude jallergies jto jfoods, jsuch jas jshellfish, jeggs, jmilk, jand
jchocolate. j
j
A jnurse jin jan jICU jis jassessing ja jclient jwho jhas ja jtraumatic jbrain jinjury. jWhich jof
jthe j
j
following jfindings jshould jthe jnurse jidentify jas ja jcomponent jof jCushing's jtriad?
j-
j
Bradycardia
j
j
,A jclient jwho jhas jincreased jintracranial jpressure jfrom ja jtraumatic jbrain jinjury jcan
j
j
develop jbradycardia, jwhich jis jone jcomponent jof jCushing's jtriad. jThe jother
components jof jCushing's jtriad jare jsevere jhypertension jand ja jwidened jpulse
j
j
pressure.
j
A jnurse jis jplanning jto jirrigate jand jdress ja jclean, jgranulating jwound jfor ja jclient jwho
j
has ja jpressure jinjury. jWhich jof jthe jfollowing jactions jshould jthe jnurse jtake? j- jUse
ja j
j
30-mL jsyringe
j
j
The jnurse jshould juse ja j30-mL jto j60-mL jsyringe jwith jan j18- jor j19- jgauge jcatheter
jto j
deliver jthe jideal jpressure jof j8 jpounds jper jsquare jinch j(psi) jwhen jirrigating ja jwound.
j
To jmaintain jhealthy jgranulation jtissue, jthe jwound jirrigation jshould jbe jdelivered jat
j
between j4 jand j15 jpsi.
j
A jnurse jin jan jemergency jdepartment jis jreviewing jthe jprovider's jprescriptions jfor
ja j
client jwho jsustained ja jrattlesnake jbite jto jthe jlower jleg. jWhich jof jthe jfollowing
j
prescriptions jshould jthe jexpect? j- jAdminister jan jopioid janalgesic jto jthe jclient. j j
j
The jnurse jshould jexpect ja jprescription jfor jan jopioid janalgesic jto jpromote jcomfort
j
j
following ja jrattlesnake jbite.
j
A jnurse jis jreviewing jthe jhealth jrecord jof ja jclient jwho jis jscheduled jfor jallergy jskin
jtesting. jThe jnurse jshould jpostpone jthe jtesting jand jreport jto jthe jprovider jwhich jof
jthe jfollowing jfindings? j(Click jon jthe j"Exhibit" jbutton jfor jadditional jinformation jabout
jthe jclient). j- jCurrent jmedications j j
j
The jnurse jshould jreview jthe jclient's jmedication jrecord jand jidentify jmedications,
jincluding jACE jinhibitors, jbeta jblockers, jtheophylline, jnifedipine, jand
jglucocorticoids, jsuch jas jprednisone, jthat jcan jalter jthe jallergy jskin jtest jresults.
jThese jmedications jcan jdiminish jthe jclient's jreaction jto jthe jallergens. jThe jnurse
jshould jnotify jthe jprovider jand jinstruct jthe jclient jto jdiscontinue jprednisone jfor j2
jweeks jbefore jallergy jskin jtesting. j
j
A jnurse jis ja jcaring jfor ja jclient jwho jis jon jbed jrest jand jhas ja jnew jprescription jfor
jenoxaparin jsubcutaneous. jWhich jof jthe jfollowing jactions jshould jthe jnurse jtake? j-
jInject jthe jmedication jinto jthe janterolateral jabdominal jwall. j j
j
j
The jnurse jshould jinject jthe jmedication jinto jthe janterolateral jor jposterolateral
abdominal jwall jto jenhance jmedication jabsorption jand jprevent jhematoma jformation.
j
j
A jnurse jis jcaring jfor ja jclient jwho jhas ja jstage jIII jpressure jinjury. jWhich jif
jthe
following jfindings jcontribute jto jdelayed jwound jhealing? j- jUrine joutput j25 jmL/hr
j
j
Urinary joutput jreflects jfluid jstatus. jInadequate jurine joutput jcan jindicate jdehydration,
j
, j
which jcan jdelay jwound jhealing.
j
A jnurse jis jcaring jfor ja jclient jwho jhas ja jnew jprescription jfor jtotal jparenteral jnutrition
j(TPN). jThe jclient jis jto jreceive j2,000 jkcal jper jday. jThe jTPN jsolution jhas j500kcal/L.
jThe jIV jpump jshould jbe jset jat jhow jmany jmL/hr? j(Rounding jto jthe jnearest jwhole
jnumber.) j- j167 jmL/hr j
j
A jnurse jis jteaching ja jclient jwho jhas ja jfamily jhistory jof jcolorectal jcancer. jTo jhelp
j
j
mitigate jthis jrisk, jwhich jof jthe jfollowing jdietary jalterations jshould jthe jnurse
j j
recommend? j- jAdd jcabbage jto jthe jdiet.
j
To jhelp jreduce jthe jrisk jfor jcolorectal jcancer, jthe jclient jshould jconsume ja jdiet jthat
jis jhigh jin jfiber, jlow jin jfat, jand jlow jin jrefined jcarbohydrates. jBrassica jvegetables
jsuch jas jcabbage, jcauliflower, jand jbroccoli, jare jhigh jin jfiber. j
j
A jnurse jis jcaring jfor ja jclient jwho jhas ja jprescription jfor jsilver jsulfadiazine jcream jto
jbe japplied jto jher jburn jwounds. jThe jnurse jshould jevaluate jthe jclient jfor jwhich jof
jthe jfollowing jlaboratory jfindings? j- jLeukopenia j j
j
Transient jleukopenia jis jan jadverse jeffect jof jsilver jsulfadiazine. j
j
A jnurse jis jteaching ja jclient jwith jsystemic jerythematosus jwho jhas ja jnew jprescription
j
j
for jprednisone. jThe jnurse jshould jinstruct jthe jclient jto jmonitor jfor jwhich jof jthe
j j
following jadverse jeffects jof jthis jmedication? j- jInfection
j
The jnurse jshould jinstruct jthe jclient jto javoid jcontact jwith jpeople jwho jare jill jand
jmonitor jfor jmanifestations jof jan jinfection jsuch jas ja jfever jor ja jsore jthroat. j
Prednisone jcan jsuppress jthe jclient's jimmune jresponse jand jmask jthe
jmanifestations jof jan jinfection. j
j
A jnurse jis jproviding jpreoperative jteaching jto ja jclient jwho jwill jundergo ja jtotal
jlaryngectomy. jWhich jof jthe jfollowing jstatements jindicates jthat jthe jclient
junderstands jthe jimpact jof jthe jsurgery? j- j"I junderstand jthat jI jwill jhave ja jpermanent
jtracheostomy jafter jthe jsurgery." j j
j
With ja jpartial jlaryngectomy, jthe jtracheostomy jis jtemporary. jThis jclient jwill jhave
ja j
j
total jlaryngectomy, jso jthe jtracheostomy jwill jbe jpermanent.
j
A jnurse jis jassessing ja jclient jwho jhas jsystemic jscleroderma. jWhich jof jthe jfollowing
j
j
findings jshould jthe jnurse jexpect? j- jFinger jcontractures
j
Scleroderma jis ja jchronic jdisease jthat jcan jcause jthickening, jhardening, jor
jtightening jof jthe jskin, jblood jvessels, jand jinternal jorgans. jThere jare j2 jtypes jof
jscleroderma: jlocalized jscleroderma, jwhich jmainly jaffects jthe jskin, jand jsystemic
jscleroderma, jwhich jcan jaffect jinternal jorgans. jManifestations jinclude jskin jchanges,
jRaynaud's jphenomenon, jarthritis, jmuscle jweakness, jand jdry jmucous jmembranes.
jWith jscleroderma jthe jbody jproduces jand jdeposits jtoo jmuch jcollagen, jcausing
jthickening jand jhardening. jIn jaddition jto jthe jclient's jskin jand jsubcutaneous jtissues
jbecoming jincreasingly jhard jand jrigid, jthe jextremities jstiffen jand jlose jmobility.
jContractures jdevelop jwith jadvanced jsystemic jscleroderma junless jclients jfollow ja
jregimen jof jrange-of-motion jand jmuscle-strengthening jexercises. j
