ATI Medical Surgical Assessment F
A nurse is caring for a client with a history of congestive heart failure at risk for
development of fluid volume excess. The nurse should monitor for which of the
following that is a manifestation of left sided heart failure?
Swelling of the fingers and hands
Jugular neck vein distension
3+ ankle edema
Dyspnea with a cough that is worse at night - Dyspnea with a cough that is worse at
night
Dyspnea with a cough that is worse at night is an indication of left-sided heart failure.
Left-sided heart failure causes blood to back up in the heart and lungs with
decreased distribution of blood throughout the body.
Which client problem should receive highest priority when a client is admitted with an
acute exacerbation of rheumatoid arthritis?
Difficulty with hygiene and grooming
Impaired physical mobility
Body-image disturbance
Anxiety - Impaired physical mobility
When setting priorities for nursing care, physiological needs should be addressed
first according to Maslow's Hierarchy of Needs. Reducing the client's pain will help
with other needs, such as hygiene and grooming.
A nurse is caring for a client with hypoparathyroidism. Because of the potential
electrolyte disturbance associated with this diagnosis, the nurse should observe the
client for evidence of which of the following?
Elevated blood pressure
Involuntary muscle spasms
Cold intolerance
Weight loss - Involuntary muscle spasms
A decrease in parathormone secretion leads to hypocalcemia (decreased serum
calcium levels), which may cause tetany. Involuntary muscle spasms are a common
symptom associated with hypothyroidism.
A client with glaucoma is admitted for surgery the following day. The client is to
continue treating the glaucoma with pilocarpine (Pilocar) 2% 1 drop 4 times a day.
While instilling this medication, an appropriate nursing action is which of the
following?
Instruct the client to blink several times after instillation of the medication.
Ask the client to look straight ahead.
,Place the medication in the conjunctival sac applying pressure to the puncta for 1 to
2 min.
Dab excess medication from the eye using a cotton ball 10 to 15 seconds after
instillation. - Place the medication in the conjunctival sac applying pressure to the
puncta for 1 to 2 min.
Eye drops are instilled into the conjunctival sac and pressure applied to the puncta
for 1 to 2 min to prevent loss of medication into the nasal lacrimal duct and into the
systemic circulation.
A client has sprained an ankle while playing soccer. For the first 24 hr following the
injury, the nurse should instruct the client to do which of the following?
Perform gentle range of motion (ROM) exercises on the ankle joint to prevent
contractures.
Keep moist heat on the ankle to prevent muscle spasm.
Keep the foot in a dependent position to aide circulation to the foot.
Keep ice on the ankle to prevent edema. - Keep ice on the ankle to prevent edema.
Ice or cold will constrict blood vessels to the injured area decreasing swelling. Nerve
impulse transmission will also be reduced, resulting in analgesia to the injured area
and a reduction of muscle spasms. Ice applications should not exceed 20 to 30 min
per application.
A nurse is assisting with the discharge of a client newly diagnosed with diabetes.
When reviewing information about proper foot care, which of the following would be
appropriate to include?
Soak feet every night in warm water.
Wear clean cotton socks daily.
Walk barefoot at home when possible.
Get fitted for shoes in the morning. - Wear clean cotton socks daily.
Cotton socks should be worn by clients who are diabetic. They are soft and will wick
excess moisture away from the foot.
Following a transient ischemic attack (TIA), a client is alert, slightly confused, and
has a blood pressure of 204/102 mm Hg. The client is also incontinent of urine.
When contributing to the client's plan of care, which nursing action would be
appropriate?
Offer the client a bedpan every 2 hr.
Place an adult diaper on the client and check every 2 hr.
Request a prescription for an indwelling urinary catheter from the client's provider.
Ambulate the client to the bathroom every 4 hr. - Offer the client a bedpan every 2
hr.
The effects of a TIA are usually temporary, and the nurse should try to help the client
regain bladder control. This option helps the client regain bladder control, uses an
appropriate time interval (2 hr) for bladder training, and keeps the client safe by
maintaining bed rest.
, A nurse is reinforcing teaching to a client recently diagnosed with systemic lupus
erythematosus (SLE). Which statement made by the client indicates to the nurse an
accurate understanding of the home management of SLE?
"I will need to take prednisone when I am having an exacerbation of the disease."
"I'm thankful this condition only affects the skin because I will just need to stay out of
the sun."
"A warm shower for 10 to 15 minutes every evening will really help to loosen up my
joints."
"A mild fever is common with SLE and usually does not require medical
intervention." - "I will need to take prednisone when I am having an exacerbation of
the disease."
SLE is an autoimmune disorder characterized by flares or exacerbations with
periodic remissions. It affects the skin as well as joints, organs, and any structure in
the body that contains connective tissue. Prednisone (Deltasone) is the medication
most commonly given to decrease the body's inflammatory response and
subsequently decrease pain in affected joints/organs/tissues and fatigue. Long-term
therapy with corticosteroids pose significant side effects so clients are usually
weaned off these medications when the exacerbation has subsided.
A nurse is caring for a client who has undergone a hip arthroplasty. The nurse
reminds the client that the purpose of an abduction pillow following arthroplasty is to
do which of the following?
Raise the bed linens off the client's feet preventing plantar flexion.
Keep the client's heels off the bed to prevent pressure ulcers.
Position the client off of the operative site while in bed.
Prevent dislocation of the hip during position changes or movement. - Prevent
dislocation of the hip during position changes or movement.
Total hip arthroplasty is a surgical procedure to reconstruct a diseased hip joint. The
head of the femur is removed, along with the lining of the acetabulum (hip socket).
The head of the femur is replaced with a metal ball and stem, and the acetabulum is
replaced with a plastic or metal cup. Following surgery, the client must be on "hip
precautions" to prevent dislocation of the new hip joint. The abduction pillow is a
wedge-shaped pillow that is placed between the legs. The purpose of the abduction
pillow is to prevent adduction beyond the midline of the body following total hip
replacement during position changes or client movement.
TQLogicTM The most important step of TQLogic used in answering this question is
comprehension and relies on basic nursing knowledge. In examining the critical
element of the test question, the issue of the question is the purpose of an abductor
pillow following hip arthroplasty. An abduction pillow or splint is used following total
hip arthroplasty to prevent adduction beyond the midline of the body and prevent
possible dislocation.
A client who is admitted to the hospital after experiencing a tonic clonic seizure is
scheduled for a routine electroencephalogram (EEG). In preparing the client for the
EEG, the nurse should explain that the client will undergo which of the following?
Remain NPO 6 to 8 hr prior to the EEG.
Receive a sedative the night prior to the EEG.
A nurse is caring for a client with a history of congestive heart failure at risk for
development of fluid volume excess. The nurse should monitor for which of the
following that is a manifestation of left sided heart failure?
Swelling of the fingers and hands
Jugular neck vein distension
3+ ankle edema
Dyspnea with a cough that is worse at night - Dyspnea with a cough that is worse at
night
Dyspnea with a cough that is worse at night is an indication of left-sided heart failure.
Left-sided heart failure causes blood to back up in the heart and lungs with
decreased distribution of blood throughout the body.
Which client problem should receive highest priority when a client is admitted with an
acute exacerbation of rheumatoid arthritis?
Difficulty with hygiene and grooming
Impaired physical mobility
Body-image disturbance
Anxiety - Impaired physical mobility
When setting priorities for nursing care, physiological needs should be addressed
first according to Maslow's Hierarchy of Needs. Reducing the client's pain will help
with other needs, such as hygiene and grooming.
A nurse is caring for a client with hypoparathyroidism. Because of the potential
electrolyte disturbance associated with this diagnosis, the nurse should observe the
client for evidence of which of the following?
Elevated blood pressure
Involuntary muscle spasms
Cold intolerance
Weight loss - Involuntary muscle spasms
A decrease in parathormone secretion leads to hypocalcemia (decreased serum
calcium levels), which may cause tetany. Involuntary muscle spasms are a common
symptom associated with hypothyroidism.
A client with glaucoma is admitted for surgery the following day. The client is to
continue treating the glaucoma with pilocarpine (Pilocar) 2% 1 drop 4 times a day.
While instilling this medication, an appropriate nursing action is which of the
following?
Instruct the client to blink several times after instillation of the medication.
Ask the client to look straight ahead.
,Place the medication in the conjunctival sac applying pressure to the puncta for 1 to
2 min.
Dab excess medication from the eye using a cotton ball 10 to 15 seconds after
instillation. - Place the medication in the conjunctival sac applying pressure to the
puncta for 1 to 2 min.
Eye drops are instilled into the conjunctival sac and pressure applied to the puncta
for 1 to 2 min to prevent loss of medication into the nasal lacrimal duct and into the
systemic circulation.
A client has sprained an ankle while playing soccer. For the first 24 hr following the
injury, the nurse should instruct the client to do which of the following?
Perform gentle range of motion (ROM) exercises on the ankle joint to prevent
contractures.
Keep moist heat on the ankle to prevent muscle spasm.
Keep the foot in a dependent position to aide circulation to the foot.
Keep ice on the ankle to prevent edema. - Keep ice on the ankle to prevent edema.
Ice or cold will constrict blood vessels to the injured area decreasing swelling. Nerve
impulse transmission will also be reduced, resulting in analgesia to the injured area
and a reduction of muscle spasms. Ice applications should not exceed 20 to 30 min
per application.
A nurse is assisting with the discharge of a client newly diagnosed with diabetes.
When reviewing information about proper foot care, which of the following would be
appropriate to include?
Soak feet every night in warm water.
Wear clean cotton socks daily.
Walk barefoot at home when possible.
Get fitted for shoes in the morning. - Wear clean cotton socks daily.
Cotton socks should be worn by clients who are diabetic. They are soft and will wick
excess moisture away from the foot.
Following a transient ischemic attack (TIA), a client is alert, slightly confused, and
has a blood pressure of 204/102 mm Hg. The client is also incontinent of urine.
When contributing to the client's plan of care, which nursing action would be
appropriate?
Offer the client a bedpan every 2 hr.
Place an adult diaper on the client and check every 2 hr.
Request a prescription for an indwelling urinary catheter from the client's provider.
Ambulate the client to the bathroom every 4 hr. - Offer the client a bedpan every 2
hr.
The effects of a TIA are usually temporary, and the nurse should try to help the client
regain bladder control. This option helps the client regain bladder control, uses an
appropriate time interval (2 hr) for bladder training, and keeps the client safe by
maintaining bed rest.
, A nurse is reinforcing teaching to a client recently diagnosed with systemic lupus
erythematosus (SLE). Which statement made by the client indicates to the nurse an
accurate understanding of the home management of SLE?
"I will need to take prednisone when I am having an exacerbation of the disease."
"I'm thankful this condition only affects the skin because I will just need to stay out of
the sun."
"A warm shower for 10 to 15 minutes every evening will really help to loosen up my
joints."
"A mild fever is common with SLE and usually does not require medical
intervention." - "I will need to take prednisone when I am having an exacerbation of
the disease."
SLE is an autoimmune disorder characterized by flares or exacerbations with
periodic remissions. It affects the skin as well as joints, organs, and any structure in
the body that contains connective tissue. Prednisone (Deltasone) is the medication
most commonly given to decrease the body's inflammatory response and
subsequently decrease pain in affected joints/organs/tissues and fatigue. Long-term
therapy with corticosteroids pose significant side effects so clients are usually
weaned off these medications when the exacerbation has subsided.
A nurse is caring for a client who has undergone a hip arthroplasty. The nurse
reminds the client that the purpose of an abduction pillow following arthroplasty is to
do which of the following?
Raise the bed linens off the client's feet preventing plantar flexion.
Keep the client's heels off the bed to prevent pressure ulcers.
Position the client off of the operative site while in bed.
Prevent dislocation of the hip during position changes or movement. - Prevent
dislocation of the hip during position changes or movement.
Total hip arthroplasty is a surgical procedure to reconstruct a diseased hip joint. The
head of the femur is removed, along with the lining of the acetabulum (hip socket).
The head of the femur is replaced with a metal ball and stem, and the acetabulum is
replaced with a plastic or metal cup. Following surgery, the client must be on "hip
precautions" to prevent dislocation of the new hip joint. The abduction pillow is a
wedge-shaped pillow that is placed between the legs. The purpose of the abduction
pillow is to prevent adduction beyond the midline of the body following total hip
replacement during position changes or client movement.
TQLogicTM The most important step of TQLogic used in answering this question is
comprehension and relies on basic nursing knowledge. In examining the critical
element of the test question, the issue of the question is the purpose of an abductor
pillow following hip arthroplasty. An abduction pillow or splint is used following total
hip arthroplasty to prevent adduction beyond the midline of the body and prevent
possible dislocation.
A client who is admitted to the hospital after experiencing a tonic clonic seizure is
scheduled for a routine electroencephalogram (EEG). In preparing the client for the
EEG, the nurse should explain that the client will undergo which of the following?
Remain NPO 6 to 8 hr prior to the EEG.
Receive a sedative the night prior to the EEG.
