medsurg practice test B ATI
A nurse is assessing for compartment syndrome in a client who has a short leg
cast. Which of the following findings should the nurse identify as a manifestation
of this condition?
- bounding pedal pulse
- capillary refill less than 2 seconds
- pain that increases with passive movement
- areas of warmth on the cast - CORRECT ANSWER-Pain that increases with
passive movement
The nurse should identify that a client who has compartment syndrome
experiences pain that increases with passive movement. Compartment
syndrome results from a decrease in blood flow in the extremity caused by a
decrease in the muscle compartment size due to a cast that is too tight.
A nurse is providing teaching to a client who has a severe form of stage II Lyme
disease. Which of the following statements made by the client reflects an
understanding of the teaching?
- "I will need to take antibiotics for 1 year"
- "my partner will need to take an antiviral medication"
- "my joints ache because I have Lyme disease"
- "I bruise easily because I have Lyme disease" - CORRECT ANSWER-"My
joints ache because I have Lyme disease"
Lyme disease is a vector-borne illness transmitted by the deer tick. The disease
course occurs in three stages beginning with joint and muscle pain in stage I. If
left untreated, these symptoms continue throughout stage II and, by stage III,
become chronic. Other chronic complications include memory problems and
fatigue.
A nurse is preparing to administer phenytoin 600 mg PO daily to a client. The
amount available is oral solution 125 mg/5 mL. How many mL should the nurse
,administer? (Round the answer to the nearest whole number. Use a leading zero
if it applies. Do not use a trailing zero.) - CORRECT ANSWER-24 mL
5 x = 24
A nurse is caring for a client who has an arterial line. Which of the following
actions should the nurse take?
- flush the line before administering antibiotics
- position the client in Trendelenburg to obtain measurements
- have the client bear down when readings are obtained
- place a pressure bag around the flush solution - CORRECT ANSWER-place a
pressure bag around the flush solution
The nurse should place a pressure bag around the flush solution of 0.9% sodium
chloride because the pressure from an artery is greater than that of the line.
A nurse is updating the plan of care for a client who is receiving chemotherapy.
Which of the following findings should the nurse identify as the priority?
- report of sore throat
- report of memory loss
- alopecia
- mucositis - CORRECT ANSWER-Report of sore throat
which could be a manifestation of an infection. The client is at risk for
neutropenia due to myelosuppression; therefore, an infection could lead to
sepsis. [the rest are expected findings from chemotherapy]
A nurse is reviewing the medical record of a client who has systemic lupus
erythematosus (SLE). Which of the following findings should the nurse expect?
- facial butterfly rash
- bradycardia
- esophagitis
- interstitial fibrosis - CORRECT ANSWER-Facial butterfly rash
, A butterfly rash is a manifestation of SLE. It appears as a dry, red rash on the
client's cheeks and nose and can disappear during times of remission.
A nurse is planning care for a client who is postoperative following a
parathyroidectomy. Which of the following actions should the nurse identify as the
priority?
- use pillows to support the client's head and neck
- offer opioid medication
- place a tracheotomy tray at the bedside
- place the client in semi-fowler's position - CORRECT ANSWER-Place a
tracheostomy tray at the bedside
in case of airway obstruction
A nurse is assessing a client who has diabetes insipidus. Which of the following
findings should the nurse expect?
- low urine specific gravity
- hypertension
- bounding peripheral pulses
- hyperglycemia - CORRECT ANSWER-Low urine specific gravity
Decreased water reabsorption by the renal tubules is caused by an alteration in
antidiuretic hormone release or the kidneys' responsiveness to the hormone.
[1.005-1.030 is normal]
A nurse is providing teaching to a client who has stage II cervical cancer and is
scheduled for brachytherapy. Which of the following instructions should the nurse
include?
- "you will have an implant placed twice each month for the duration of the
treatment"
- "you should remain at least 6 feet away from others between treatments"
- "you should expect to have blood in your urine for a few days after treatment"
A nurse is assessing for compartment syndrome in a client who has a short leg
cast. Which of the following findings should the nurse identify as a manifestation
of this condition?
- bounding pedal pulse
- capillary refill less than 2 seconds
- pain that increases with passive movement
- areas of warmth on the cast - CORRECT ANSWER-Pain that increases with
passive movement
The nurse should identify that a client who has compartment syndrome
experiences pain that increases with passive movement. Compartment
syndrome results from a decrease in blood flow in the extremity caused by a
decrease in the muscle compartment size due to a cast that is too tight.
A nurse is providing teaching to a client who has a severe form of stage II Lyme
disease. Which of the following statements made by the client reflects an
understanding of the teaching?
- "I will need to take antibiotics for 1 year"
- "my partner will need to take an antiviral medication"
- "my joints ache because I have Lyme disease"
- "I bruise easily because I have Lyme disease" - CORRECT ANSWER-"My
joints ache because I have Lyme disease"
Lyme disease is a vector-borne illness transmitted by the deer tick. The disease
course occurs in three stages beginning with joint and muscle pain in stage I. If
left untreated, these symptoms continue throughout stage II and, by stage III,
become chronic. Other chronic complications include memory problems and
fatigue.
A nurse is preparing to administer phenytoin 600 mg PO daily to a client. The
amount available is oral solution 125 mg/5 mL. How many mL should the nurse
,administer? (Round the answer to the nearest whole number. Use a leading zero
if it applies. Do not use a trailing zero.) - CORRECT ANSWER-24 mL
5 x = 24
A nurse is caring for a client who has an arterial line. Which of the following
actions should the nurse take?
- flush the line before administering antibiotics
- position the client in Trendelenburg to obtain measurements
- have the client bear down when readings are obtained
- place a pressure bag around the flush solution - CORRECT ANSWER-place a
pressure bag around the flush solution
The nurse should place a pressure bag around the flush solution of 0.9% sodium
chloride because the pressure from an artery is greater than that of the line.
A nurse is updating the plan of care for a client who is receiving chemotherapy.
Which of the following findings should the nurse identify as the priority?
- report of sore throat
- report of memory loss
- alopecia
- mucositis - CORRECT ANSWER-Report of sore throat
which could be a manifestation of an infection. The client is at risk for
neutropenia due to myelosuppression; therefore, an infection could lead to
sepsis. [the rest are expected findings from chemotherapy]
A nurse is reviewing the medical record of a client who has systemic lupus
erythematosus (SLE). Which of the following findings should the nurse expect?
- facial butterfly rash
- bradycardia
- esophagitis
- interstitial fibrosis - CORRECT ANSWER-Facial butterfly rash
, A butterfly rash is a manifestation of SLE. It appears as a dry, red rash on the
client's cheeks and nose and can disappear during times of remission.
A nurse is planning care for a client who is postoperative following a
parathyroidectomy. Which of the following actions should the nurse identify as the
priority?
- use pillows to support the client's head and neck
- offer opioid medication
- place a tracheotomy tray at the bedside
- place the client in semi-fowler's position - CORRECT ANSWER-Place a
tracheostomy tray at the bedside
in case of airway obstruction
A nurse is assessing a client who has diabetes insipidus. Which of the following
findings should the nurse expect?
- low urine specific gravity
- hypertension
- bounding peripheral pulses
- hyperglycemia - CORRECT ANSWER-Low urine specific gravity
Decreased water reabsorption by the renal tubules is caused by an alteration in
antidiuretic hormone release or the kidneys' responsiveness to the hormone.
[1.005-1.030 is normal]
A nurse is providing teaching to a client who has stage II cervical cancer and is
scheduled for brachytherapy. Which of the following instructions should the nurse
include?
- "you will have an implant placed twice each month for the duration of the
treatment"
- "you should remain at least 6 feet away from others between treatments"
- "you should expect to have blood in your urine for a few days after treatment"
