Ati rn medical surgical proctored
A home health nurse is caring for a client who has COPD. The client tells the nurse that
he becomes short of breath while eating despite the use of home oxygen. What
instructions should the nurse include? - ansDrink beverages at the end of meals
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? - ans"I don't cross my legs anymore".
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? - ansStop the infusion
A nurse in an orthopedic clinic is reinforcing teaching with a client who has
osteoarthritis. What instructions should the nurse include to promote comfort? -
ansSleep on a firm mattress
A nurse is admitting a client who is suspected having active tuberculosis (TB). What
action should should the nurse take first? - ansInstitute airborne precautions
A nurse is assisting in the care of a client who has manifestations of sepsis. What
provider prescriptions should the nurse implement first? - ansInitiate oxygen at 4 L/min
via nasal cannula
A nurse is assisting in the plan of care for a client who has a recent left hemispheric
stroke. What action should the nurse include in the plan? - ansUse simple verbal cues
when directing tasks
A nurse is assisting with an educational program for clients who have newly diagnosed
with diabetes mellitus. What instruction should the nurse include in the program
regarding insulin? - ansOpened insulin can be stored on a cool countertop away from
light
A nurse is caring for a client following a gastrectomy. What action should the nurse take
to decrease episodes of dumping syndrome? - ansPlace the client in the supine position
after meals
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? - ansVisitors must don a gown & gloves prior to entering the client's room.
A nurse is caring for a client who has a new cast on her left forearm and report severe
pain in the affected arm with numbness in the fingers. The nurse finds the skin is pale
and cold with sluggish capillary refill. What fracture complication should the nurse
suspect? - ansCompartment syndrome
,Ati rn medical surgical proctored
A nurse is caring for a client who has a prescription for digoxin 0.25mg PO daily. While
taking the client's apical pulse, the nurse notes a rate of 58/ min. What action should the
nurse take? - ansWithhold the dose
A nurse is caring for a client who has an intestinal obstruction & reports a new onset of
nausea. The client has an NG tube set at low intermittent suction & is receiving
continuous IV infusion of 0.9% sodium chloride. What action should the nurse take first?
- ansCheck for kinks in the NG tube
A nurse is caring for a client who has dementia due to Alzheimer's disease. What action
should the nurse take to reduce the client's confusion? - ansEncourage reminiscence of
past experiences
A nurse is caring for a client who has meningococal pneumonia. Which of the following
personal protective equipment should the nurse use? - ansMask (this disease requires
droplet precautions)
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? - ans"Tell
me more about the way you are feeling."
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? - ansPulmonary Embolism
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? - ansEncourage the client to use an incentive spirometer
every hour while awake
A nurse is caring for a client who is 24hr postoperative following an abdominal surgery.
What finding requires immediate attention from the nurse? - ansOxygen saturation of
88%
A nurse is caring for a client who is in Buck's traction. What intervention should the
nurse perform to reduce skin breakdown? - ansKeep the skin dry and free of
perspiration
A nurse is caring for a client who is post operative following a transurethral resection of
the prostate (TURP) and is receiving continuous bladder irrigation. The nurse notes
decreased output from the urethral catheter. What prescription should the nurse expect
the provider to order? - ansIrrigate the urethral catheter with 0.9% sodium chloride
A nurse is caring for a client who reports shortness of breath and has an oxygen
saturation of 90%. What action should the nurse take? - ansAdminister oxygen via nasal
cannula
, Ati rn medical surgical proctored
A nurse is caring for a female client who is being treated for dehydration due to nausea
& vomiting. What finding should the nurse report to the provider? - ansHeart rate 120/
min
A nurse is caring for four clients. What conditions should the nurse identify as a risk for
developing vascular disease? - ansDiabetes mellitus
A nurse is collecting data from a client who has chronic kidney disease with
hyperkalemia. What finding should the nurse expect related to hyperkalemia? -
ansBradycardia
A nurse is collecting data from a client who has hypokalemia. What finding should the
nurse identify as the priority? - ansDysrhythmia
A nurse is collecting data from a client who has hypothyroidism. What manifestation
should the nurse expect? - ansBradycardia
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? - ansHave a designated stethoscope in the client's
room
A nurse is contributing to the plan of care for a client who has just transferred to the
medical-surgical unit from PACU following a right total knee arthroplasty. What
interventions should the nurse include in the plan? - ansAssist the client to change
position every 2hr
A nurse is contributing to the plan of care for a client who has pericarditis. What position
should the nurse plan to place the client to decrease plan? - ansUpright, leaning forward
A nurse is contributing to the plan of care for a client who has tuberculosis (TB). What
intervention should the nurse include? - ansPlace the client in a negative pressure
airflow room
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? -
ansEncourage 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 monitoring a client who has a wrist cast and reports intense itching
underneath the cast. What action should the nurse take? - ansBlow cool air into the cast
using a blow dryer on a cool setting
A home health nurse is caring for a client who has COPD. The client tells the nurse that
he becomes short of breath while eating despite the use of home oxygen. What
instructions should the nurse include? - ansDrink beverages at the end of meals
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? - ans"I don't cross my legs anymore".
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? - ansStop the infusion
A nurse in an orthopedic clinic is reinforcing teaching with a client who has
osteoarthritis. What instructions should the nurse include to promote comfort? -
ansSleep on a firm mattress
A nurse is admitting a client who is suspected having active tuberculosis (TB). What
action should should the nurse take first? - ansInstitute airborne precautions
A nurse is assisting in the care of a client who has manifestations of sepsis. What
provider prescriptions should the nurse implement first? - ansInitiate oxygen at 4 L/min
via nasal cannula
A nurse is assisting in the plan of care for a client who has a recent left hemispheric
stroke. What action should the nurse include in the plan? - ansUse simple verbal cues
when directing tasks
A nurse is assisting with an educational program for clients who have newly diagnosed
with diabetes mellitus. What instruction should the nurse include in the program
regarding insulin? - ansOpened insulin can be stored on a cool countertop away from
light
A nurse is caring for a client following a gastrectomy. What action should the nurse take
to decrease episodes of dumping syndrome? - ansPlace the client in the supine position
after meals
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? - ansVisitors must don a gown & gloves prior to entering the client's room.
A nurse is caring for a client who has a new cast on her left forearm and report severe
pain in the affected arm with numbness in the fingers. The nurse finds the skin is pale
and cold with sluggish capillary refill. What fracture complication should the nurse
suspect? - ansCompartment syndrome
,Ati rn medical surgical proctored
A nurse is caring for a client who has a prescription for digoxin 0.25mg PO daily. While
taking the client's apical pulse, the nurse notes a rate of 58/ min. What action should the
nurse take? - ansWithhold the dose
A nurse is caring for a client who has an intestinal obstruction & reports a new onset of
nausea. The client has an NG tube set at low intermittent suction & is receiving
continuous IV infusion of 0.9% sodium chloride. What action should the nurse take first?
- ansCheck for kinks in the NG tube
A nurse is caring for a client who has dementia due to Alzheimer's disease. What action
should the nurse take to reduce the client's confusion? - ansEncourage reminiscence of
past experiences
A nurse is caring for a client who has meningococal pneumonia. Which of the following
personal protective equipment should the nurse use? - ansMask (this disease requires
droplet precautions)
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? - ans"Tell
me more about the way you are feeling."
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? - ansPulmonary Embolism
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? - ansEncourage the client to use an incentive spirometer
every hour while awake
A nurse is caring for a client who is 24hr postoperative following an abdominal surgery.
What finding requires immediate attention from the nurse? - ansOxygen saturation of
88%
A nurse is caring for a client who is in Buck's traction. What intervention should the
nurse perform to reduce skin breakdown? - ansKeep the skin dry and free of
perspiration
A nurse is caring for a client who is post operative following a transurethral resection of
the prostate (TURP) and is receiving continuous bladder irrigation. The nurse notes
decreased output from the urethral catheter. What prescription should the nurse expect
the provider to order? - ansIrrigate the urethral catheter with 0.9% sodium chloride
A nurse is caring for a client who reports shortness of breath and has an oxygen
saturation of 90%. What action should the nurse take? - ansAdminister oxygen via nasal
cannula
, Ati rn medical surgical proctored
A nurse is caring for a female client who is being treated for dehydration due to nausea
& vomiting. What finding should the nurse report to the provider? - ansHeart rate 120/
min
A nurse is caring for four clients. What conditions should the nurse identify as a risk for
developing vascular disease? - ansDiabetes mellitus
A nurse is collecting data from a client who has chronic kidney disease with
hyperkalemia. What finding should the nurse expect related to hyperkalemia? -
ansBradycardia
A nurse is collecting data from a client who has hypokalemia. What finding should the
nurse identify as the priority? - ansDysrhythmia
A nurse is collecting data from a client who has hypothyroidism. What manifestation
should the nurse expect? - ansBradycardia
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? - ansHave a designated stethoscope in the client's
room
A nurse is contributing to the plan of care for a client who has just transferred to the
medical-surgical unit from PACU following a right total knee arthroplasty. What
interventions should the nurse include in the plan? - ansAssist the client to change
position every 2hr
A nurse is contributing to the plan of care for a client who has pericarditis. What position
should the nurse plan to place the client to decrease plan? - ansUpright, leaning forward
A nurse is contributing to the plan of care for a client who has tuberculosis (TB). What
intervention should the nurse include? - ansPlace the client in a negative pressure
airflow room
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? -
ansEncourage 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 monitoring a client who has a wrist cast and reports intense itching
underneath the cast. What action should the nurse take? - ansBlow cool air into the cast
using a blow dryer on a cool setting
