ATI Med Surg Proctored Exam 2019

1. Nurse is preparing to administer thrombolytic therapy to a client with ischemic stroke. which is an appropriate nursing action? - • Elevate HOB between 25-30 degrees 2. Nurse is teaching about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching? - • Holds breaths about 305 seconds before exhaling 3. Nurse is assessing a client who is 12 hr post op following a colon resection. Which of the following findings should the nurse report to the surgeon - • Absent Bowel Sounds 4. Nurse is caring for a client who has diabetes insipidus. Which of the following meds should the nurse plan to administer? - Desmopressin 5. Nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily for 3 years. Which of the following tests should the nurse monitor? - Stool for occult blood 6. A nurse in the ED is assessing a client. Which of the following actions should the nurse take first? - Initiate Airborne Precautions 7. A nurse is contacting the provider of a client who has cancer and is experiencing breakthrough pain. Which of the following prescriptions should the nurse anticipate? - Fentanyl 8. Nurse is admitting a client who reports chest pain and has been places on a telemetry monitor. Which of the following should the nurse analyze to determine whether the client is experiencing a MI - ST segment 9. Nurse is teaching a client who has ovarian cancer about skin care following radiation treatment. Which of the following should the nurse include - • Pat the skin on the radiation site to dry it 10. A nurse is caring for a client receiving blood transfusion. Nurse observes client has bounding peripheral pulse, HTN, distended jugular veins. The nurse should anticipate admin which of the following meds? - Furosemide 11. A nurse is assessing a client who is getting Magnesium Sulfate IV for tx of hypomagnesemia. Which of the following indicates effectiveness? - • Apical Pulse 82 12. Lumbar puncture positioning: Cannonball position while on one side or by having the client stretch over an overbid table is sitting is preferred - • Its a picture just choose the one that corresponds with the position I described** answer is C 13. A nurse is reviewing ABG results: pH 7.42, PaCO2: 30; HCO3: 21. Indication for which of the following conditions? - • Uncompensated respiratory acidosis 14. Nurse is preparing to administer daily meds to a client undergoing a procedure that requires IV contrast dye. Which of the following meds should the nurse hold? - Metformin 15. Nurse is caring for a client who is experiencing seizures secondary to meningitis. What should be included in the plan of care? SATA! - • Have suction at bedside, Dim overhead lights 16. Nurse is caring for pt who has a pressure ulcer with necrotic tissue and requires wet-to-damp dressing. Which of the following types of debridement should the nurse include in the plan of care. - Mechanical 17. Nurse is caring for a female with toxic shock. Which finding should nurse expect? - Generalized Rash 18. Nurse is preparing to administer a med for a client through a non-tunneled percutaneous central catheter. Which of the following actions should the nurse take? - Flush catheter with 10mL of NS 19. Nurse is caring for pt admitted with nausea, vomit, and possible bowel obstruction. NG tube is placed and set to low intermittent suction. Which of the following findings should the nurse report? - Distended and firm 20. Nurse is reviewing the MAR of a pt with DI. Which of the following finding should the nurse expect? - Urine specific gravity 1.001 21. Nurse is caring for a pt who has hyperthyroidism and develops thyroid storm. Which of the following instructions should the nurse give to the client regarding management of thyroid storm? - • You will need a cooling blanket to lower your body temperature 22. Nurse is reviewing the MAR of a client who has acute gout. The nurse should expect an increase in which of the lab values? - Uric Acid 23. Nurse is preparing to administer peritoneal dialysis to a client. Which of the following actions should the nurse take? - • Hang drainage bag below the client's abdomen 24. Nurse in the Ed is caring for pt who has deep partial-thickness burns over 30% of his body, including upper chest and abdomen. Which of the following actions is the nurse's priority? - insert 18-gauge IV catheter 25. Nurse is presenting an in-service about Parkinson’s disease. Which of the following statements should nurse include int he teaching? - • PD results from a decreased amount of dopamine in the client's brain 26. A nurse is caring for a client who has a serum sodium level of 150. Which action should the nurse take? - Administer hypotonic IV fluids to the client 27. Nurse is caring for a client who takes lisinopril for HTN. Which of the following client statements indicates an adverse effect of the medication? - • I have a nagging, dry cough. Heightened sense of taste 28. Nurse is proving discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching? - • I should expect less than 25mL of secretions per day 29. Nurse is caring for a pt who has DM and has been following a treatment plan for 3 months. Which lab values should nurse monitor to determine long-term glycemic control? - Glycosylated Hgb level 30. Nurse is providing discharge teaching to a client to has chronic UTI. Client has a prescription for cipro. What should nurse include in teaching? - • Drink 2 to 3 L of fluid per day 31. A nurse is providing teaching to pt who has a DVT. Which of the following is a risk factor for a DVT? - Oral Contraceptives 32. Nurse is caring for pt with Cushing’s. Which of the following actions should the nurse take first? - 33. Nurse is assessing pt with nephrotic syndrome. Which of the following findings should the nurse expect? - Proteinuria 34. Med math gtt/min - 20 drops per min 35. Right-sided heart failure. Which assessment finding should nurse expect? - • Pitting Edema 36. Newly inserted chest tube. Nurse should clarify which of the following orders? - Administer Morphine IV Bolus 37. Nurse is teaching a client who is taking an ACE inhibitor for heart failure. Which of the following instructions should the nurse include for the management for heart failure? - Obtain daily weight 38. Nurse is providing discharge teaching to a client who has permanent pacemaker. Which of the following statements by the client indicates understanding of the teaching? - I need to check my pulse rate every day for a full minute. 39. Nurse in a clinic is providing preventive teaching to an older adult 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? SATA!! - Influenza, Pneumococcal polysaccharide, Herpes Zoster 40. Nurse is assessing a pt who is 4hr post op following an arterial revascularization of the left femoral artery. Which of the following findings should the nurse report to the provider immediately? - Pallor in the affected extremity 41. Nurse is caring for an older adult client who has not been eating. Which of the following findings indicates dehydration? - Diminished peripheral pulses 42. Nurse is preparing to discharge a client who has a halo device and is reviewing new prescriptions from the provider. The nurse should clarify which of the following prescriptions with the provider - • May operate a motor vehicle when no longer taking analgesics 43. Nurse is assessing for early signs of compartment syndrome for a client who has a short left fiberglass cast. Which of the following can the nurse expect? - Intense Pain with Movement 44. A nurse is caring for a client who is post op following coronary artery bypass surgery and reports shortness of breath. The nurse administers oxygen at 3 L/mim and obtains arterial blood gases 60 mins later. Which of the following lab values indicates positive response to the oxygen therapy? - PaO2 90mmHg 45. Nurse is performing cranial nerve assessment on a client following a head injury. Which of the following findings has impaired function of the vestibulocochlear nerve? - Disequilibrium with movement 46. 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? - • GCS score changes from 14 to 9 47. Nurse is caring for a client who presents to the ED after experiencing heat stroke. Which of the following actions should the nurse take? - • Administer Lactated Ringers or apply a cooling blanket 48. Nurse is caring for a client who is taking furosemide. client has a potassium level of 3.1. Which of the following should the nurse assess first? - • Cardiovascular status 49. 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? - • Ask client to empty his bladder prior to the procedure 50. Nurse is caring for a client who is 6hr post op thyroidectomy. The client reports tingling and numbness in the hands. The nurse should identify this as a sign of which following electrolyte imbalances - Hypocalcemia 51. A nurse is assessing a client 15 minutes after the start of a transfusion of 1 unit of packed RBCs. Which of the following findings is an indication of a hemolytic transfusion reaction? - Hypotension 52. Nurse in an ED is caring for a client who has sinus bradycardia. Which of the following actions should the nurse take first? - Administer atropine to the client