ATI Med Surg Proctored Exam 2 2024
Respiratory Alkalosis S/S - lethargy
lightheadedness
confusion
tachycardia
dysrhythmias related to hypokalemia
nausea
vomiting
epigastric pain
numbness and tingling of the extremities
hyperventilation (tachypnea)
A nurse is contributing to the plan of care for an older adult client who is at risk for
Osteoporosis. Which intervention should the nurse include to prevent bone loss? - Encourage
weight bearing exercises (such as walking because it can help maintain bone mass by
reducing bone demineralization, thus helping to prevent osteoporosis.)
A nurse is caring for a client who has meningococal pneumonia. Which of the following
personal protective equipment should the nurse use? - Mask (this disease requires droplet
precautions)
A nurse is reinforcing teaching with a client who is taking insulin Glargine. What information
should the nurse include in the teaching? - This type of insulin should be given at the same
time everyday. (It is released over a 24hr period)
A home health nurse is reinforcing teaching with a client about preventing complications of
peripheral vascular disease. What statement by the client indicates that they are adhering to
the nurse's instructions? - "I don't cross my legs anymore".
A nurse is caring for a client who has a methicillin-resistant Staphlococcus aureus (MRSA)
infections in a surgical wound. What information should the nurse plan to share with visitors?
- Visitors must don a gown & gloves prior to entering the client's room.
A nurse is reinforcing teaching with a client who has heart failure and a new prescription for
hydrochlorothiazide. What should the client report to the provider? - Onset of nausea
A nurse is reinforcing discharge teaching with a client who has hearing loss. What action
should the nurse take when communicating with the client? - Rephrase client instructions
when not understood.
A nurse is caring for a client who is 1 day post operative following a hip arthroplasty. The
client is exhibiting hypotension, tachycardia, & tacky-nearly. The nurse should recognize
these findings as what complication? - Pulmonary Embolism
A nurse is monitoring a client who recently had a cast placed on the right lower extremity for
a bone fracture. What finding should the nurse recognize as abnormal? - Lack of sensation
between the first and second toes
, A nurse reinforcing teaching with a client who has systemic lupus erythematosus (SLE) and
is to begin taking methylprednisolone orally. What should the nurse include in the teaching? -
Limit contact with large groups of people
A nurse is caring for a client who is 24hr postoperative following abdominal surgery & has
an NG tube. What action should the nurse plan to take to decrease the risk of postoperative
complications? - Encourage the client to use an incentive spirometer every hour while awake
A nurse is collecting data from a client who has chronic kidney disease with hyperkalemia.
What finding should the nurse expect related to hyperkalemia? - Bradycardia
A nurse is assisting in the care of a client who has manifestations of sepsis. What provider
prescriptions should the nurse implement first? - Initiate oxygen at 4 L/min via nasal cannula
A nurse is caring for a client who has terminal pancreatic cancer. The client states, "I don't
think I can go on any longer." What response should the nurse make? - "Tell me more about
the way you are feeling."
A nurse is collecting data from a client who has hypokalemia. What finding should the nurse
identify as the priority? - Dysrhythmia
A nurse is caring for a client who is in Buck's traction. What intervention should the nurse
perform to reduce skin breakdown? - Keep the skin dry and free of perspiration
A nurse is contributing to the plan of care for a client who has a methicillin-resistant
Staphylococcus aureus (MRSA) infections and is on contract isolation precautions. What
action should the nurse take? - Have a designated stethoscope in the client's room
A nurse enters the room of a client whose transfusion of packed RBCs was initiated 15 min
ago by the RN. The client reports dyspnea and urticaria. What action should the nurse
perform first? - Stop the infusion
A nurse is preparing to auscultate the bowel sounds of a client who has a mechanical bowel
obstruction in the descending colon. When listening in the left upper quadrant, the nurse
should identify this sound as what? - Hyperactive bowel sounds
A nurse is preparing to administer furosemide to a client who has heart failure. What should
the nurse report before administering the medication? - Decreased potassium
A nurse is reinforcing teaching about joint protection with a client who has an acute
exacerbation of rheumatoid arthritis. What information should the nurse include in the
teaching? - Apply cold packs to the joints
A nurse is collecting data from a client who has hypothyroidism. What manifestation should
the nurse expect? - Bradycardia
A nurse is reinforcing teaching with an older adult client who has osteoporosis. What
instructions should the nurse include in the teaching? - Take the calcium supplements with
meals
Respiratory Alkalosis S/S - lethargy
lightheadedness
confusion
tachycardia
dysrhythmias related to hypokalemia
nausea
vomiting
epigastric pain
numbness and tingling of the extremities
hyperventilation (tachypnea)
A nurse is contributing to the plan of care for an older adult client who is at risk for
Osteoporosis. Which intervention should the nurse include to prevent bone loss? - Encourage
weight bearing exercises (such as walking because it can help maintain bone mass by
reducing bone demineralization, thus helping to prevent osteoporosis.)
A nurse is caring for a client who has meningococal pneumonia. Which of the following
personal protective equipment should the nurse use? - Mask (this disease requires droplet
precautions)
A nurse is reinforcing teaching with a client who is taking insulin Glargine. What information
should the nurse include in the teaching? - This type of insulin should be given at the same
time everyday. (It is released over a 24hr period)
A home health nurse is reinforcing teaching with a client about preventing complications of
peripheral vascular disease. What statement by the client indicates that they are adhering to
the nurse's instructions? - "I don't cross my legs anymore".
A nurse is caring for a client who has a methicillin-resistant Staphlococcus aureus (MRSA)
infections in a surgical wound. What information should the nurse plan to share with visitors?
- Visitors must don a gown & gloves prior to entering the client's room.
A nurse is reinforcing teaching with a client who has heart failure and a new prescription for
hydrochlorothiazide. What should the client report to the provider? - Onset of nausea
A nurse is reinforcing discharge teaching with a client who has hearing loss. What action
should the nurse take when communicating with the client? - Rephrase client instructions
when not understood.
A nurse is caring for a client who is 1 day post operative following a hip arthroplasty. The
client is exhibiting hypotension, tachycardia, & tacky-nearly. The nurse should recognize
these findings as what complication? - Pulmonary Embolism
A nurse is monitoring a client who recently had a cast placed on the right lower extremity for
a bone fracture. What finding should the nurse recognize as abnormal? - Lack of sensation
between the first and second toes
, A nurse reinforcing teaching with a client who has systemic lupus erythematosus (SLE) and
is to begin taking methylprednisolone orally. What should the nurse include in the teaching? -
Limit contact with large groups of people
A nurse is caring for a client who is 24hr postoperative following abdominal surgery & has
an NG tube. What action should the nurse plan to take to decrease the risk of postoperative
complications? - Encourage the client to use an incentive spirometer every hour while awake
A nurse is collecting data from a client who has chronic kidney disease with hyperkalemia.
What finding should the nurse expect related to hyperkalemia? - Bradycardia
A nurse is assisting in the care of a client who has manifestations of sepsis. What provider
prescriptions should the nurse implement first? - Initiate oxygen at 4 L/min via nasal cannula
A nurse is caring for a client who has terminal pancreatic cancer. The client states, "I don't
think I can go on any longer." What response should the nurse make? - "Tell me more about
the way you are feeling."
A nurse is collecting data from a client who has hypokalemia. What finding should the nurse
identify as the priority? - Dysrhythmia
A nurse is caring for a client who is in Buck's traction. What intervention should the nurse
perform to reduce skin breakdown? - Keep the skin dry and free of perspiration
A nurse is contributing to the plan of care for a client who has a methicillin-resistant
Staphylococcus aureus (MRSA) infections and is on contract isolation precautions. What
action should the nurse take? - Have a designated stethoscope in the client's room
A nurse enters the room of a client whose transfusion of packed RBCs was initiated 15 min
ago by the RN. The client reports dyspnea and urticaria. What action should the nurse
perform first? - Stop the infusion
A nurse is preparing to auscultate the bowel sounds of a client who has a mechanical bowel
obstruction in the descending colon. When listening in the left upper quadrant, the nurse
should identify this sound as what? - Hyperactive bowel sounds
A nurse is preparing to administer furosemide to a client who has heart failure. What should
the nurse report before administering the medication? - Decreased potassium
A nurse is reinforcing teaching about joint protection with a client who has an acute
exacerbation of rheumatoid arthritis. What information should the nurse include in the
teaching? - Apply cold packs to the joints
A nurse is collecting data from a client who has hypothyroidism. What manifestation should
the nurse expect? - Bradycardia
A nurse is reinforcing teaching with an older adult client who has osteoporosis. What
instructions should the nurse include in the teaching? - Take the calcium supplements with
meals
