ATI Med-Surg Final Exam Graded A

1. a nurse is providing discharge teaching to a client who has a new prescription for sublingual nitro, which of the following client statements indicates an understanding of the teaching? - i should lie down when i take this medication 2. a nurse is providing discharge teaching to an older adult client following a total hip arthroplasty. which of the following instructions should the nurse include in the teaching? - install a raised toilet seat in your bathroom 3. a nurse is planning care for a client following a cardiac cath. which of the following actions should the nurse take? - maintain the clients affected extremity in extension 4. a nurse is caring for a client who has a lower extremity fracture and a prescription for crutches. which of the following statements indicates the client is adapting to their role change? - i will need to have my partner take over shopping for the groceries and cooking the meals for us 5. a nurse is providing discharge teaching to a client who has an impaired immune system due to chemo. which of the following instructions should the nurse include in the teaching? - change your pets liter box daily 6. a nurse is caring for a client who has a contusion and reports thirst. the clients urinary output was 4000 ml over the past 24 hours. the nurse should anticipate what prescription for which of the following IV medications? - desmopressin 7. a nurse in a clinic receives a phone call from a client who received an ace inhibitor and reports nagging dry cough. which of the following responses by the nurse is appropriate? - sucking on a lozenge may reduce the frequency of your cough 8. a nurse is taking an admin history from a client who reports raynauds disease. which of the following assessment findings should the nurse identify as a parental trigger for exacerbation of the disease? - using nicotine transdermal patch 9. a nurse is caring for a client with a central line and notes the tubing has become disconnected. the client develops dyspnea and tachycardia. which of the following actions should the nurse take first? - clamp the catheter 10. a nurse is completing an assessment of an older client and notes reddened areas over the bony prominences, but the clients skin is intact. which of the following interventions should the nurse include in the plan of care? - support the bony prominences with pillows 11. a home health nurse is making an initial visit to a client who has MS. which of the following actions is the priority for the nurse to take? - provide coping strategies for client and family 12. a nurse in the ER is assessing a client. which of the following actions should the nurse take first? (click on the exhibit button) - initiate airborne precautions 13. a nurse is reviewing the medical record of a client to identify factors for colon cancer. the nurse identify which of the following findings as an increasing the clients risk? - history of crohns disease 14. a nurse is caring for a client who is scheduled for a mastectomy. the client tells the nurse "im not sure i want to have a mastectomy" which of the following statements should the nurse make? - i can give you additional information about the procedure 15. a nurse is preparing to admin a unit of packed RBCs to a client who is anemic. Identify the sequence of steps the nurse should follow? – 1. obtain venous access using 19- gauge needle 2. obtain the unit of packed RBCs from blood bank 3. verify blood compatibility with another nurse 4. initiate blood transfusion 5. remain with the client for 15-30 minutes 16. a nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. which of the following statements by the clients indicates understanding of the teaching? - i should expect less than 25ml of secretions per day in the drainage device 17. a critical care nurse is assessing a client who has a severe head injury. in response to painful stimuli, the client does not open her eyes, displays decerebrate posturing and makes incomprehensible sounds, which of the following glasgow coma scale scores should the nurse assign? - 5 18. a nurse is providing discharge teaching to a client who has HF and instructs him to limit sodium intake to 2g per day. which of the following statements by the client indicate an understanding of the teaching? - i can have a frozen fruit juice bar for dessert 19. a nurse is preparing to perform ocular irrigation for a client following a chemical splash to the eye. which of the following actions should the nurse plan to do first? - instill 0.9% sodium chloride solution into the affected eye 20. a nurse is assessing a client following extubation from a ventilator. for which of the following findings should the nurse intervene immediately. - stridor 21. a nurse is reviewing a lab report of a client who has acute pancreatitis. which of the following findings should the nurse expect? - elevated blood gluocse 22. a nurse is reviewing the medical record of a client who has diabetes insipidus. which of the following findings would the nurse expect? - urine specific gravity 1.001 23. a nurse is planning care for a client who has a PE. which of the following interventions should the nurse include? - initiate a continuous IV heparin infusion 24. a nurse is providing discharge teaching to a client who is recovering from a sickle cell crisis. which of the following instructions should the nurse include? - avoid extremely hot or cold temperatures 25. a nurse in the ER is caring for a client with hypovolemic shock. which of the following actions should the nurse take first? - insert a large bore IV catheter 26. a nurse is caring for a client who has an arteriovenous graft. which of the following findings indicate adequate circulation on the graft? - palpable thrill 27. a nurse is caring for a client in DKA. which of the following is a priority intervention? - infuse 0.9% normal saline 28. a nurse is assessing a client who has HF and is receiving loop diuretics. which of the following indicates hypokalemia? - muscle weakness 29. a nurse is providing discharge teaching to a client who has an ileostomy. which of the following client statements indicates an understanding of the teaching? - i will expect my stools to be loose 30. a nurse is caring for a client who is receiving TPN through a central line. the current bag is nearly empty, and a new bag is unavailable from the pharmacy. which of the following actions should the nurse take? - switch the infusion to a 10% dextrose solution 31. a nurse is caring for a client who is 6 hours post op following a thyroidectomy. the client reports tingling and numbness in the hands. the nurse should identify this as a sign of which of the following electrolyte imbalances? - hypocalemia 32. a nurse in an office is caring for a client with total vision loss and is the handler of a service dog, which of the following actions should the nurse take to show consideration for the client and the service animal? - consult the client before approaching the dog 33. a nurse is reviewing medication taken at home with a client who has angina, which of the following statements by the client indicate an understanding of the teaching? - i should lie down before taking a dose of isosorbide dinitrate 34. a nurse in the post anesthesia unit is assessing a client following an appendectomy and finds a 2cm area of blood on the post op dressing. which of the following actions should the nurse take? - apply pressure 35. a nurse is caring for a client who is receiving mechanical ventilation, which of the following interventions should the nurse implement? - provide oral care every 2 hours 36. a nurse is planning care for a client who has full thickness burns on his lower extremities, which of the following interventions should the nurse include? - apply new gloves when alternating between wound areas 37. a nurse is providing teaching for a client who has tuberculosis and a new prescription for pyrazinamide. the nurse should instruct the client to notify the provider if which of the following adverse effects occurs? - jaundice 38. a nurse is planning care for a client who has left side hemiplegia following a stroke. which of the following actions should the nurse include in the plan of care? - place a plate guard on the clients meal tray 39. a nurse is performing an ear irrigation for a client. which of the following actions should the nurse take? - point the tip of the syringe toward to top of the ear canal 40. a nurse is caring for a client who has a history of chemotherapy-induced nausea and vomiting? which of the following medications should the nurse administer prior to chemo? - ondansetron 41. a nurse is preparing to discharge a client who has a halo device and is reviewing new prescription from the provider. the nurse should clarify which of the following prescriptions? - may operate a motor vehicle when no longer taking analgesics 42. a nurse is providing discharge teaching to a client who has TB. which of the following information should the nurse include in the teaching? - you will return in 2 weeks to provide sputum specimen 43. a nurse is assessing a client who has left sided heart failure. which of the following findings should the nurse expect? - frothy sputum 44. a nurse is planning care for a client who has osteoarthritis of the knees. which of the following should the nurse include in the plan? - place a large pillow under the clients knees when resting 45. a nurse is caring for a client who is getting continuous bladder irrigation following a transurethral resection of the prostate. the client reports sharp lower abdominal pain. which of the following actions should the nurse take first? - check the clients urine output 46. a nurse is caring for a client getting chemo and requests information about acupuncture to relieve some of the side effects, which of the following findings should the nurse identify as a contraindication to getting alternative therapy? - lymphedema 47. a nurse is preparing the admin LR via continuous IV infusion at 200ml/hr. the Iv tubing has a drop factor of 10 drops/ml. how many gtt/min should the nurse set the IV pump to admin? - 33 48. a nurse is providing instructions about foot care for a client who has peripheral artery disease. the nurse should identify which of the following statements by the client to indicate understanding of the teaching? - i rest in my recliner with my feet elevated for about an hour every afternoon 49. a nurse in a providers office is teaching a client about the self management of GERD. which of the following instructions should the nurse include? - sleep with the head of the bed elevated 6 inches 50. a nurse is caring for a client who is post op following a partial thyroidectomy. which of the following findings is the priority for the nurse to report to the provider? - high pitched sound on inspiration 51. a nurse is caring for a client who is 2 days post op following a below the knee amputation and asks about the purpose of maintaining an elastic bandage around the residual limb of the extremity. which of the following is an appropriate response by the nurse? - why do you think your life is over? 52. a nurse is planning care for a client who is 8 hour post op following a CABG. which of the following assessments should the nurse plan to perform first? - measure the clients core body temperature 53. a nurse is providing instructions to a client who has primary syphilis. which of the following instructions should the nurse include in the discharge teaching? - you will need to be monitored for 15 minutes after getting each dose of medication 54. a nurse is caring for a client who has hypotension, cool and clammy, tachycardia, and tachypnea. in which of the following positions should the nurse place the client? - feel elevated