NURSING 250 MEDSURG 1 PROCTORED 1 Exam Guide Questions completed ; Answers provided

NURSING 250 MEDSURG 1 PROCTORED 1 Exam Guide Questions completed ; Answers provided 1. A nurse is assessing a client who has lef-sided heart failure. Which of the following fndings should the nurse expect? a. Bradycardia- more tachycardia cuz of a failing ventricle , SNS is actvated to compensate . b. Flushed skin- duskly it wIll look like c. Frothy sputum-Lef sided- can be blood tnged d. Jugular vein distenton→ Right Ratonale: ATI MS: pg. 198 ch 32 pdf Lef side: dyspnea, orthopnea, fatgue, pulmonary congeston, frothy sputum, organ failure such as oliguria. Right Side: Jugular vein distenton, ascending dependent edema, abdominal distenton, polyuria ar rest, liver enlargement, 2. A nurse is assessing a client who is experiencing renal colic from a calculus in lef renal pelvis. Identfy the area where the nurse should expect the client to have referred pain. ( Find “hot spots” in the artwork) Pain travels downward to the inguinal area and lower back Renal colic occurs in the kidney area. Referred pain is somewhere that happens in another place other than where the pain should be felt. 2. A nurse is caring for a client who is receiving peritoneal dialysis and notes a decrease in the dialysate flow rate. Which of the following actons should the nurse take? (Select all the apply?). Check answer i read pg 644-647 med surg it’s not so specifc p. 370 ch 57 pdf a. monitor the access site for drainage.- to check for sxs of infecton. b. Strip the catheter tubing c. Measure the amount of the dialysate outlow d. Raise the client to high fowlers positon- they must lie supine e. Positon the client to her other side. 3. A nurse is planning to insert an indwelling catheter for a female client. Which of the following actons should the nurse plan to take? At video tutorials foley a. Collect urine specimen from the drainage bag 1 hr afer inserton b. Raise the head of the bed to 45 degrees prior to inserton c. Secure the catheter to the client's inner thigh d. Atach the bag to the rail of the bed. –under non movable area 6. A nurse is providing teaching for a client who has age-related macular degeneraton which of the following informaton should the nurse include in the teaching a. A possible cause of this problem is long-term lack of dietary protein b. You probably have a Detachment of your retna -vision is like having curtains over eyes c. You probably have notced a decline in your central vision d. The doctor can perform surgery to correct the start paying the folds in your retna Ratonale: ATI MS: PG. 63 Macular degeneraton, ofen called age-related macular degeneraton (AMD), is the central loss of vision that affects the macula of the eye. NO cure , happens alot in old people. Sxs: distorted vision, blurred vision, caused by smoking, female, HTN, diet lacking carotene.7. A nurse is assessing a client who has cirrhosis. Which of the following fndings is the priority for the nurse to report? P . 357 ch 55 pdf Med surg a. Platelets 70,000/mm3- risk of bleed normal range is 150,000 - 300,00- ABCS is compromised automatcally . b. Distended abdomen- expected c. Alkaline phosphatase 125 units/L -norm normal is 30 -120 D. Clay colored stools- bile not on your shit 8. A nurse is preparing to discontnue long-term total parenteral nutriton (TPN) therapy for a client for a client. The nurse should plan to discontnue the TPN gradually to reduce the risk of which of the following adverse effects? Old med surge docs we used a. Hyperglycemia b. Diarrhea c. Constpaton d. Hypoglycemia (Repeat) Since your body is producing enough insulin to take on higher loads, you must taper it down to avoid hypoglycemia with lower concentratons of TPN Abruptly discontnuing TPN will cause rebound hypoglycemia 9. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actons should the nurse plan to take? P . 250 chapter 40 pdf p . 678 lewis a. Administer the unit of packed RBC’s over 1 hr- 2- 4 hr its must be given for 2 -4 hours. older adults b. Obtain the client’s frst set of vital signs 1 hr afer initatng the transfusion- you get vital signs at the inital frst 15 to 30 minutes of the transfusion. c. Initate venous access with a 21-gauge needle - no more than 19, for a regular adult it is 18 or 20 . d. Use Y tubing with 0.9% sodium chloride when administering the transfusion. Pg 249 10. TOXIC SHOCK SYNDROME- same 11. A nurse is providing discharge teaching to an older adult client who had an exacerbaton of COPD. The client is to start flutcasone by metered-dose inhaler. WHich of the following instructons should the nurse include? ( C) p . 132 ch 22 a. Use flutcasone as needed for shortness of breath.- flutcasone used to treat inflammaton. b. Limit fluid intake to 1 L per day. - drink plenty to avoid dehydraton. 2-3 liters. c. Obtain a yearly influenza immunizaton. - reduce risk of infecton. d. Assist use of pursed-lip breathing.- this is also one of the interventons the nurse does but the queston ask about flutcasone. It is a steroid, and we all know steroids decresaes inflammaton but also depress our immunue system. So getng a flu shot is priority. 12. A nurse is providing discharge teaching to an older adult client following a lef total hip arthroplasty. Which of the following instructons should the nurse include in the teaching? a. “You can cross your legs at the ankles when sitng down.” -avoid flexion contracton b. “Clean the incision daily with hydrogen peroxide.”- soap and water c. “Install a raised toilet seat in your bathroom.” Pg 437 also use straight chairs with arms, abducton pillow between the legs, avoid low chairs, and flexion of hip greater than 90 degrees. NO crossing legs , no turing on operatve side. d. “You should use an incentve spirometer every 8 hrs.”- once every hour at least 13. Missing 14. A nurse is caring for a client who is postoperatve following a femur fracture. Which of the following fndings should the nurse report to the provider immediately? a. The client reports shortness of breath - embolism ABCS p . 457 chapter 71 b. The client has a temperature of 38.1 C (100.5F) c. The clients incision is red and warm d. The client reports incision pain15. A nurse is planning care for a client who Clostridium difcile gastroenterits. Which of the following is an appropriate nursing acton? P . 290 ch 46 pdf a. Place the client in a protectve environment b. Obtain a stool specimen with gloves→ CONTACT ISO c. Clean surfaces with chlorhexidine-bleach D. Wash hands with alcohol-based hand rub. 16. A nurse is setng up a sterile feld before performing a dressing change on client who is postoperatve. Which of the following actons should the nurse plan to take to maintain the sterile feld? (select all the apply) a. Grasp 2.5 cm (1 in ) of the outer edge to open the surgical wrap- 1 inch form broder is always non sterile so its ok to touch it . b. Select a work surface at the nurses waist level- body mchiancis . c. Apply sterile gloves before opening the pack- sterile package must be opened frst before donning sterile gloves d. Open the frst flap of the sterile package toward the nurse's body- must be AWAY frst , then sides , then TOWARDS the nurse . e. Place a surgical pack with a sterile drape on the work surface. 17. A nurse is caring for a client who has acute appendicits. Which of the fndings is the priority to the provider? Ch 23 p . 143 PEDIATRICS pdf also p 944 lewis a. Nausea- has not burst b. Flank pain - normal c. Fever - has not burst d. Rigid abdomen - muscles contract because it exploded- can lead to rupture and infecton also HR ELEVATED, shallow and rapid respiratons, pulse is weak. . 18. A nurse is caring for a client who is receiving radiaton. The client reports nauseas since the therapy was initated. Which of the following consideratons should the nurse include when planning the clients meals? P . 583 ch 91 also ch 16 p 269 of the lewis book a. Offer frequent, high-carbohydrate meals- several small meals a day is preffered. b. Offer highly seasoned foods- you want COLD , dry , foods. Cooking stmulates odors that lead to nausea. c. Offer a snack prior to radiaton therapy- several small meals a day is recommended. d. Offer hot beverages with meals- hot foods can stmulate nausea. Beverage with meals leads to nausea. 19. A nurse is caring for a client who is receiving mechanical ventlaton. Which of the following interventons should the nurse implement? (D) page 208-209 not sure which answer Empty water from the ventlator tubing daily. ( -INFECTION CONTROL: water that collects in the ventlator tubing can create a breeding ground for bacteria which may lead to VAP. Sucton the client’s airway every 4 hr.(Sucton every 2 hr and as needed. p.157) Maintain the client in supine positon. (should repositon pt to help with secretons) Perform oral care every 2 hr.( you do oral care but not every 2hrs ) 20. A nurse in an emergency department is assessing a client who has cirrhosis of the liver. Which of the following is a priority fnding? ( C) a. Palmar erythema b. Spider angiomas c. Mental confusion (RM 10 Ch.55 p.359 pdf - too much bilirubin in the blood went to the brain and now caused mental encephalopathy) d. Yellow Sclera 21. A nurse is preparing to administer bumetanide to a client who has heart failure. Which of the following assessment fndings should indicate effectveness of the medicaton a. Bowel sounds present in 4 quadrants on auscultaton b. Alert and oriented to tme place and personc. Lung sounds clear - it is Bumex d. Apical pulse 80 Ratonale: MS RM 10 Ch.32 p.198-9 23. A nurse is caring for a client who has hypertension and has a new prescripton for lisinopril. The nurse should consult with the provider about which of the following medicaton in the client's medicaton administraton record? a. Potassium chloride ** found on medscape b. evothyroxine c. Acetaminophen d. Metormin Ratonale: Pharm RM 7.0 Ch.20 p.151; Hyperkalemia is a complicaton for Lisinopril; avoid any salt substtutes containing K+. 24. A nurse is planning care for a client who is 1 day postoperatve following an open cholecystectomy. Which of the following interventons should the nurse include in the plan or care? a. Avoid use of antcoagulants - use it b. Place pillow under client knees - stasis danger c. Discourage leg exercises while in bed - you need it d. Apply compression stocking in lower extremites Ratonale: It’s common post-op, also, resume regular actvity afer 4-6 wks. 25. What interferes with warfarin therapy a. Potatoes (Potassium) Oranges (Vit C) b. Bananas (Potassium) c. Cauliflower - Huge Vitamin K remember veggies Ratonale: Avoid any interacton with Vitamin K when on antcoagulant therapy, and dark, leafy veggies (or just any veggies) are THE source for it. 26. A nurse is administering furosemide 80 to a client with pulmonary edema. Which of the following assessment fndings indicates the nurse that the medicaton is effectve? P , 144 ch 19 pharm pdf a. Elevaton in BP b. Adventtous breath sounds c. Weight loss of 1.8 kg (4lb) in the past 24 hr d. Respiratory rate of 24/min 27. A nurse is caring for a client who has Cushing’s disease. Which of the following fndings should the nurse expect? Ch 80 page 518 a. Weight loss b. Hyponatremia- increased c. Hyperglycemia d. Hypercalcemia- DECREASED ERRYTHANG is UP except K+/Ca+, both HYPO 28. A nurse is monitoring a client who has receiving 2 units packed RBCs. Which of the following manifestatons indicates a hemolytc transfusion reacton? (MS RM 10.0 Ch.40 p.250: chills, fever, low-back pain, tachycardia, flushing, hypotension, chest tghtening or pain, tachypnea, nausea, anxiety, hemoglobinuria, and an impending sense of doom) a. Back pain b. Bradycardia- should be tachycardia c. Hypertension- hypotension it will cause. d. Chills29. A PACU nurse is monitoring the drainage from a client’s NG tube following abdominal surgery. Which of the following fndings in the frst postoperatve hour should the nurse report to the provider? a. 75 mL of greenish yellow drainage (Purulent) b. 100 mL of red drainage (Sanguineous/fresh bleeding) c. 200 mL of brown drainage (Purulent) d. 150 mL of serosanguineous drainage 30. A nurse is performing an admission assessment on a client who has severe chronic kidney disease. Which of the following fndings should the nurse expect? MS RM 10.0 Ch.59 p.382 pdf a. Lethargy b. Potassium 4.0 mEq/L c. Hypotension- HTN due to fluid overload d. Serum creatnine 0.9 mg/dL- should be increased . Ratonale: Expected fndings include nausea, fatgue, lethargy, involuntary movement of legs, depression, and intractable hiccups. In most cases of chronic CKD, fndings are r/t fluid overload, including both HTN and orthostatc hypotension. 31. Missing 32. A nurse is teaching a client who has hypothyroidism. Which of the following informaton should the nurse include in the teaching? (select all the apply) pg. 886 med srg a. You will take medicaton for this conditon for several months b. You will need to eat a high-fber diet to prevent complicatons of this conditon c. You might notce that you perspire more with this conditon d. We will perform laboratory tests to monitor the effect of your medicaton e. This conditon can cause you to gain weight. 33. A nurse is caring for a client who is receiving mechanical ventlaton when the low pressure alarm sounds on the ventlator. Which of the following actons should the nurse take? P 113 ms at pdf a. Empty water from the client’s ventlator tubing b. Evaluate the client for a cuff leak - check this frst for cause of low pressure c. Sucton the client’s airway d. Increase the client’s ventlator flow rate. 34. A nurse is reviewing laboratory results for four clients who are scheduled for surgery. Which of the following laboratory values should the nurse report to the surgeon? a. INR of 1.6 (Normal 1.0-2.0) b. Platelets 95,000/mm3 (low 150,000-350,000) c. Hct 42% (Normal 42%-52% men; 37%-47% women) d. WBC 8,000/mm3 (Normal 5,000-10,000/mm3) Ratonale: MS RM 10.0 Ch.39 p.245; Normal labs35. A nurse is assessing a client who is receiving valsartan to treat heart failure. Which of the following fndings should the nurse identfy as an indicaton that the medicaton is effectve? a. Increased potassium level b. Decreased blood pressure ?? ** c. Increased heart rate ( pg 365 md srg valsartan is a aferload reducing agent, angiotensin receptor blocker ) d. Decreased urinary output 36. A nurse is providing teaching to a client following a liver biopsy 1 hour ago. Which of the following positons should the nurse instruct the client to maintain afer the procedure??? P. 882 lewis medsurg a. Prone b. Supine c. Right lateral - with minimum 2 hours, with patent bed flat. d. Lef lateral Ratonale: ATI Capstone queston; “Following a liver biopsy, the nurse should instruct the client to lie on the affected side for hemostasis to occur. The liver sits just under the rib cage on the right side of the abdomen.”37. A nurse is providing discharge teaching to a client following a modifed lef radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching? MS RM 10.0 Ch.92 p.614 a. “I will have to wait 2 months before additonal saline can be added to my breast expander” (tssue expanders have ports for additonal injecton of saline for gradual expansion & is encouraged) b. “I will perform strength building arm exercises using a 15 pound weight” (Squeeze a rubber ball, elbow flexion/extension, hand-wall climbing to promote full ROM and prevent lymphedema) c. “I should expect less than 25 ml of secretons per day in the drainage devices” d. “I will keep my lef arm flexed at the elbow as much as possible” (Elbow flexion AND extension) 38. A nurse is teaching a client who has diabetes mellitus about foot care. Which of the following instructons should the nurse include? Ch 82 page 532 a. “Wash your feet twice per day with antbacterial soap and hot water” b. “Wear loose ftng slippers around the house” c. “Wear coton rather than nylon sock” d. “Use a heatng pad to keep your feet warm at night” 39. A nurse is caring for a client following the placement of a transverse colostomy. Which of the following fndings indicates a possible complicaton? a. Client reports pain of 6 on scale from 0 to 10 b. Heart rate 110/min c. Bowel sounds hypoactve d. Stoma appears dry p. 602.. Stoma should be pink , moist , ischemia should be reported to the provider. 40. A nurse is counseling a client who has a family history of hypertension about reducing high risk for high blood pressure. Which of the following strategies should the nurse recommend? P .161 a. Engage is isometric exercises for 15 min daily b. Maintain a body mass index between 31 and 34 c. Lower total cholesterol level <200 mg/dL d. Increase dietary potassium intake 41. A nurse in the PACU is assessing a client who is postoperatve following general anesthesia. Which of the following fndings is the priority to address? P . 645 a. Piloerecton of the skin b. Vomitng upon arousal c. Decreased body temperature- increases risk for wound infecton, cardiac dysrhymias, altered absorpton of medicaton. d. Indistnct, rambling speech 42. A nurse is providing discharge teaching to the partner of a client who has a linear incision site following an open cholecystectomy. Which of the following wound care instructons should the nurse include? a. Change the dressing four tmes per day b. Use sterile gloves when performing the dressing change ??? ( they dont have to use sterile they can use clean gloves ) c. Clean from the incision to the surrounding skin d. Apply tncture of benzoin prior to removing the dressing 43. A nurse is preparing to administer vancomycin IV bolus to a client who has pneumonia. Which of the following clinical manifestatons should the nurse instruct the client to monitor for and report? a. Pallor of the extremites b. Taste of metal in the mouth c. Halo of light around objects d. Ringing in the ears- ototoxic is vanco p 359 pharm at pdf44. A nurse is caring for a client who has pancreatts and has been receiving total parenteral nutriton. Which of the following laboratory tests should the nurse monitor for overall nutritonal status? a. Prealbumin b. C reactve protein c. Creatnine d. Lipase 45. A charge nurse is called to a client’s room afer a staff nurse reports a client has had a wound evisceraton. Which of the following actons should the charge nurse take? Page 650 MS ATI PDF 10.0 im stuck with c and d . its says with cover the wound with a sterile saline soaked towel or dressing a. Atempt to reinsert the protruding viscera- DO NOT ATTEMPT TO REINSERT ORGANS b. Obtain botles of warm, sterile 0.9% sodium chloride soluton = wouldn’t you want to get sterile soluton for the dressing cover to put on the wound? c. Place the client in lef lateral recumbent positon- low fowlers hips knees bent (at book p1111 “place in supine positon with hips and knees bent”)= which is lithotomy positon, not recumbent d. Apply a frm pressure dressing across the client’s abdomen <- in practce A/B. confrmed (p1111 at book “cover wound with sterile dressing”--doesn’t mean apply frm pressure) 46. A nurse is caring for four clients. Which of the following clients is at risk for developing metabolic alkalosis? Pg 283 at a. A client who is receiving contnuous gastric suctoning b. A client who has aspiraton pneumonia c. A client who is experiencing an opioid overdose- respiratory acidosis. d. A client who has uncontrolled diabetes mellitus 47. A nurse is caring for a client who is taking digoxin 0.125 mg PO daily and is at risk for developing digoxin toxicity. The nurse should monitor the client for an imbalance of which of the following electrolytes because it can increase the risk for digoxin toxicity? a. Calcium b. Potassium c. Magnesium d. Phosphatase Ratonale: Digoxin level and Potassium levels are inversely correlated. So if you have less K+ your digoxin levels shots up leading to digoxin toxicity and if your K+ is high=digoxin level is low. 48. A nurse is assessing the abdominal wound of a client who is 3 days postoperatve following a colon resecton. Which of the following fndings should the nurse report to the provider? a. Erythema (redness can be indicatve of infecton) b. Ecchymotc skin c. Drainage (expected for 3-4 days?) d. Edema ??? 49. A nurse is completng an admission assessment for a client. The nurse should expect the provider to prescribe which of the following medicatons for the client? EXHIBIT VITAL SIGNS: Temperature (98.3 F), HR (100/min), RR (20/min), BP (152/94mmHg) a. Atorvastatn b. Allopurinol c. Metoprolol d. levothyroxine50. A nurse is assessing a client who is near the end of life following a head injury. The client has alternatng periods of rapid breathing and apnea. The nurse should document this fnding as which of the following respiratory paterns? page 75 ch 14 a. Biot’s respiratons- quick shallow respiratons followed by apnea. b. Hypoventlatory respiratons- opoid overdose c. Kussmaul respiratons- hyperglycemia d. Cheyne-Stokes respiratons- occurs during INCREASED INTRACRANIAL PRESSURE 51. A nurse is administering a unit of packed RBCs to a client and notes that there are several small clots floatng in the IV bag. Which of the following actons should the nurse take? a. Inject 5,000 units of heparin into the unit of packed RBCs b. Place the unit of packed RBCs in a warming unit for 5 min c. Return the unit of packed RBCs to the blood bank- return that shit d. Dilute the unit of packed RBCs using 50 mL of lactated Ringer’s 52. A nurse in a provider’s ofce is teaching a client about the self-management of GERD. Which of the following instructons should the nurse include? a. “Eat a light meal 1 hour before bedtme”- avoid eatng before bedtme b. “Lie down for 30 minutes afer each meal”- CANNOT BE SUPINE c. “Increase your caloric intake by 250 calories per day” d. “Sleep with the head of your bed elevated 6 inches”- Ratonale: so your acid doesn’t hit your throat when you sleep pg 309 57. A nurse is providing teaching to a client and his partner about performing peritoneal dialysis at home. When discussing peritonits, which of the following manifestatons should the nurse identfy as the earliest indicaton of this complicaton? a. Generalized abdominal pain b. Cloudy efuent c. Fever d. Increased heart rate Ratonale: Peritonits Assessment Findings : Rigid, board-like abdomen(hallmark), abd distenton, N&V, Rebound tenderness, tachycardia, FEVER. 58. A nurse is caring for a client who is receiving enteral nutriton. Which of the following interventons by the nurse will prevent aspiraton? a. Check the gastric pH following bolus feedings ( for verifying placement) b. Place the client in supine positon before initatng feedings (No; 30 degree) c. Instruct the client to perform the Valsalva maneuver afer feedings (no) d. Measure residual volume prior to bolus feedings Ratonale: Nursing measures to prevent aspiraton include verifying tube placement, checking gastric residuals, assessing bowel functon to confrm peristalsis, and elevatng the head of the patent’sbed to 30 degrees or more during feeding and at least 1 hour afer feeding. Monitor fluid and electrolyte balance carefully; additonal water may be prescribed based on the patent’s fluid status. Providing mouth care is partcularly important for patents receiving enteral feedings, as is addressing the psychosocial aspects of care. 62. Client has a pressure ulcer. Which indicates wound healing? a. Light yellow exudate (Seropurulent) b. Wound tssue frm to palpaton (frm, not healing yet) stage 1. c. Dry brown eschar (dead skin?) d. Dark red granulaton tssue p . 330 fundamentalsRatonale: Red: Healthy regeneraton of tssue Yellow: Presence of purulent drainage and slough Black: Presence of eschar that hinders healing and requires removal 63. STEPS to use of a peak flow meter a. “Stand upright” 1 b. “Seal your lips around the mouth piece”3 c. “Fill your lungs with a deep breath”2 d. “Exhale forcefully and quickly”4 e. “Record the highest of three consecutve readings”5 Ratonale: A,C,B,D,E 1. Stand up or sit up straight. 2. Make sure the indicator is at the botom of the meter (zero). 3. Take a deep breath in, flling the lungs completely. 4. Place the mouthpiece in your mouth; lightly bite with your teeth and close your lips on it. Be sure your tongue is away from the mouthpiece. 5. Blast the air out as hard and as fast as possible in a single blow. 6. Remove the meter from your mouth. 7. Record the number that appears on the meter and then repeat steps one through seven two tmes. 8. Record the highest of the three readings in an asthma diary. This reading is your peak expiratory flow (PEF). 67. Client, who is 6 hr postoperatve following applicaton of an external fxator for a tbial fracture. Which of the following actons should the nurse take? a. Palpate the dorsalis pedis pulse. b. Maintain the affected extremity in a dependent positon (ELEVATE) c. Wrap sterile gauze on the shart point of the pins (NOPE 8-12HRS) d. Adjust the clamps on the fxator flame (NEVER, MD DOES THIS) Ratonale: Elevate extremity, Monitor neurovascular status and skin integrity, Assess body image, Perform pin care every 8 to 12 hr, Monitor site for drainage, color, odor, redness, Observe for manifestatons of fat and pulmonary embolism, Provide antembolism stockings and sequental compression device to prevent deep-vein thrombosis (DVT). 68.) A nurse is preparing an in-service presentaton about the use of automated external defbrillators (AEDs). Which of the following instructons should the nurse include in the teaching? a. “Perform CPR while the AED is analyzing”-cannot due b/c analysis will be wrong b. “Positon the client on a flat surface” c. “Set the AED to 80 joules” (should be 200 joules) d. “Use an AED for a client who has A-fb” (AED is for V-fb & V-tach) Ratonale: Process of Eliminaton and Think. 69. Serum sodium level of 120 mEq/L. Which of the followings fndings should the nurse expect? P . 271 a. Hyperreflexia - Decreased DTRs b. Decreased bowel sounds - increased motlity , ab cramping, nausea. c. Confusion** d. Increased central venous pressureRatonale: MANIFESTATION OF HYPONATREMIA :Weakness, Lethargy, CONFUSION, Seizures, Headache, Anorexia, N&V, Muscle Cramps, twitching, Hypotenton, Tachycardia, Wt gain and Edema. 271 MS pdf also, headache, lethargy, muslce wekaness to the point of respiratory cimpromise, decreased DTRs, seizures, light headed , dizzy,70. Pt. taking isoniazid and rifampin, which understands? a. “I will be fnished with this medicaton regimen in 3 months” -9 months b. “I should check the whites of my eyes while taking these medicatons” - very hepatotoxic c. “I should take my mediaton with an antacid if it upsets my stomach” (Taking antacid would decrease effectveness of the medicaton so it is not advised or SHOULD not take it during treatment) d. “I will no longer be infectous afer two consecutve negatve sputum specimens” (THREE) Ratonale: Assess for toxicity because both medicaton are very toxic you are at risk for hepatotoxicity. Other choices are WRONG, Eliminate it. 72. The use of incentve spirometer. a. Positon the mouthpiece 2.5cm (1 in) from the mouth (put in ur mouth) b. Place hands on the upper abdomen during inhalaton (no hold spirometer) c. Hold breaths about 3-5 secs before exhaling (repeat) d. Exhale slowly through purse lips (With Purse lip breatng not Spirometer) Ratonale: The client who is using the spirometer should take in a deep breath and hold it for 3 to 5 seconds before exhaling. As the client exhales, the needle of the spirometer rises. This promotes lung expansion. (per ATI med surg) 1. Sit on the edge of your bed if possible, or sit up as far as you can in bed. 2. Hold the incentve spirometer in an upright positon. 3. Place the mouthpiece in your mouth and seal your lips tghtly around it. 4. Breathe in slowly and as deeply as possible. Notce the yellow piston rising toward the top of the column. The yellow indicator should reach the blue outlined area. 5. Hold your breath as long as possible. Then exhale slowly and allow the piston to fall to the botom of the column. 6. Rest for a few seconds and repeat steps one to fve at least 10 tmes every hour. 7. Positon the yellow indicator on the lef side of the spirometer to show your best effort. Use the indicator as a goal to work toward during each slow deep breath. 8. Afer each set of 10 deep breaths, cough to be sure your lungs are clear. If you have an incision, support your incision when coughing by placing a pillow frmly against it. 9. Once you are able to get out of bed safely, take frequent walks and practce the cough. 73. Pt. who is in septc shock. Which lab fndings indicate the patent is developing “multple organ dysfuncton syndrome”? a. Arterial hypoxemia (low / no O2 manifestaton of MODS) b. Decreased liver enzymes- Increased c. Decreased BUN - Increased d. Hypoglycemia - body response = increase to save body Ratonale: MODS can develop from severe hypotension and reperfusion of ischemic cells, causing further tssue injury. Inadequate tssue perfusion can cause organ failure in the lungs (adult respiratory distress syndrome), kidneys, heart (decreased coronary artery perfusion, decreased cardiac contractlity), and the gastrointestnal tract (necrosis).. So MODS happends when no O2 is being delviered 75. A nurse is reviewing a client’s laboratory values and notes a potassium level of 2.8 mEq/L. Which of the following fndings should the nurse expect? a. Hyperactve bowel sounds (Hypoactve) b. Increased blood pressure (Hypotension)c. Irregular pulse d. Exaggerated reflexes (CM of Hyperkalemia) Ratonale: Manifeston of Hypokalemia: IRREGULAR PULSE, Muscle weakness and cramping, Fatgue, Nausea, Vomitng, Irritability, Confusion, Decrease Bowel sound, Paresthesia, Dysrhythmias, Flat/ inverted T wave, 76. A nurse is caring for a client who is admited to the medical-surgical unit with a seizure disorder. Which of the following interventons should the nurse include in the plan of care? a. Teach assistve personnel how to apply restraints --> do not atempt to restrain the client b. Keep the side rails in a down positon → a) side- rails up with padding to prevent injury c. Keep a padded tongue blade at the client’s bedside → do not use padded tongue blades. d. Maintain peripheral IV access. RATIONALE: ATI MS ATI MS 36 Priority: Maintain peripheral IV access in case of emergency may administer diazepam, or lorazepam IVP followed by IV phenytoin or fosphenytoin. side- rails up with padding to prevent injury 77. A nurse is collectng a medical history from an older adult client who has hypertension and new prescripton of nadolol. Which of the following fndings should the nurse report to the provider? a. cataracts b. GERD c. Asthma d. Hypothyroidism RATIONALE: ATI PHARM 263 Avoid in clients who have asthma. Bronchoconstricton effect. And if you guys could remember about the JNC8 per Tiamson. 78. A nurse is preparing a client for a Lumbar puncture. Which of the following images indicates the positon the nurse should assess the client into for this procedure? (Here are some of the choices) But the correct one is FETAL POSITION. → FETAL POSITION or SITTING FORWARD ON THE TABLE. (ATI MS 21)78. A nurse is caring for a client who has a diabetes mellitus. The client’s ABG are ph 7.14, PaO2 90 mmHg, PaCO2 35 mmHg, and HCO3 4 mEq/L. The nurse should identfy that the client has which of the following acid-base imbalances? a. Respiratory acidosis b. Metabolic alkalosis c. Respiratory alkalosis d. Metabolic acidosis RATIONALE: ATI MS pH 7.35- 7.45 7.14 Acidosis CO2 35-45 35 compensatng HCO3 22-26 4 metabolic 80. A nurse is planning care for a client who has developed nephrotc syndrome. Which of the following dietary recommendatons should the nurse include? a. Increase Phosphorus b. Increase Potassium c. Decrease protein intake d. Decreased carbohydrate intake. à Increased carbs is what you want RATIONALE: ATI MS Nephrotc syndrome = kidney disorder characterized by massive proteinuria, hypoalbuminemia & edema AVOID excess protein, high amounts of FAT, & minimize Na → more fluid retenton 81. A nurse is planning care for a client who has new diagnosis of acute pancreatts. Which of the ff interventons should the nurse include in the plan of care? a. Administer anthypertensive meds b. Maintain the client on NPO status c. Place client in supine positon d. Monitor the client for hypercalcemia RATIONALE: ATI MS 348 NPO: no food untl pain-free 82. A nurse is assessing a client who has increased intracranial pressure. The nurse should recognize that which of the following is the frst sign of deterioratng neurological status? a. Altered level of consciousness b. Pupillary constricton c. Decortcate posturing d. Cheyne-stokes respiratons RATIONALE: ATI MS 19 All manifestaton of ICP. But FIRST sign of deterioratng neurological status is ALOC → pupillary constricton → cheyne posturing → Cheyne-stokes respiratons. You may use Glasgow coma scale to assess neurological status. 83. A nurse is obtaining a medicaton history from a client who is to start therapy with naproxen for rheumatoid arthrits. Which of the following medicatons places the client at risk for bleeding? a.) Captopril → Ace Inhibitor b.) Ibuprofen → NSAIDS c.) Digoxin → antdysrhythmic d.) Phenytoin → antconvulsant RATIONALE: ATI MS 84. A nurse is caring for an older adult client who is suspected of having septcemia. Which of the following actons is the nurse’s priority? a. Obtain a WBC count with differental b. Obtain a history to determine recent injuries. c. Obtain a blood specimen of culture and sensitvity testngd. Obtain a broad-spectrum antbiotc for rapid administraton. RATIONALE: ATI MS 85. A nurse is assessing a client following a kidney biopsy. Which of the following fndings should the nurse identfy as an indicaton that the client is experiencing internal bleeding? a. Bradycardia→ Tachycardia, Hemorrhaging b. Polyuria → Urgency, complicatons c. Flank Pain d. Increase Blood Pressure→ Hypotension, Hemorrhaging RATIONALE: ATI MS 144 Monitor for internal bleeding (measure abdominal girth and abdominal or flank pain) at least Q8hr. TBC 86. A nurse is caring for a client who has diabetes insipidus and has had a urinary output of 3,000 ml in the past 12 hr. which of the following medicatons should the nurse expect to administer to the client? a. Dopamine b. Desmopressin acetate c. Furosemide d. Spironolactone RATIONALE: ATI Pharm 532 ATI MS 499 Diabetes insipidus has defciency of ADH. Manifestaton of 3 P’s: polyuria, polyphagia, and polydipsia. Administer ADH (desmopressin) to stop polyuria and prevent dehydraton. 87. A nurse is admitng a client to a medical unit following placement of a permanent pacemaker. Which of the following fndings requires further assessment by the nurse? a. Sneezing b. Presence of a sharp spike prior to the QRS complex on the ECG c. Hiccups d. Presence of intrinsic P waves following a QRS complex on the ECG RATIONALE: ATI MS 177 Assess for hiccups, which can indicate that the generator is pacing the diaphragm. 88. A nurse is caring for a client receiving TPN who weighs 160Lb. If the RDA of protein is 0.8g/kg of body weight. How many g of protein should the client receive? 160 lbs/2.2 = 72.72 kg 0.8 g x 72.72 kg= 58g 89. A nurse is caring for a client who has an arteriovenous graf. Which of the following fndings indicates adequate circulaton of the graf? (D) a. Dilated appearance of the graf b. Normotensive blood pressure c. Absence of a bruit d. Palpable thrill RATIONALE: ATI MS Adequate circulaton of the graf has manifestaton of palpable thrill arterial and venous, indicates good blood flow and patency. 90. A nurse is providing discharge teaching for a client who is receiving treatment for genital herpes. Which of the following indicates effectve of the teaching? a. I should expect my lesions to resolve in 6 weeks b. I should expect to take my medicaton for 3 weeks c. I should use natural skin condoms during sex. → Avoid SEX d. I should apply antbiotc ointment to lesions. → Acyclovir – antviral medicaton RATIONALE: ATI MS 91. A nurse is caring for a client who has a history of chemotherapy-included nauseas and vomitng. Which of the following medicatons should the nurse administer prior to chemotherapy? a. Ondansetronb. Sertraline c. Diphenhydramine d. Methylprednisolone RATIONALE: ATI MS 581 Serotonin blockers, such as ondansetron, have been found to be effectve and are ofen administered with cortcosteroids, phenothiazines, and anthistamines 92. A nurse is preparing to administer daily medicatons to a client who is undergoing procedure at 1000 that req IV contrast dye. Which of the following routne meds to give at 0800 should the nurse withhold? a. Metoprolol b. Metormin c. Flutcasone d. Valproic Acid RATIONALE: ATI MS 364 Withhold METFORMIN for 24 hr. before the procedure (risk for lactc acidosis from contrast dye with iodine). 93. A nurse is preparing to assist with the inserton of a non-tunneled central venous catheter for a client who is malnourished. Which of the following actons should the nurse plan to take? a. Confrm the correct positon of the line by obtaining a blood sample. - Xray b. Instruct the client to cough as the catheter is inserted. - Cough may shif vessels = danger c. Place the head of the client’s bed lower than the foot. d. Cleanse the site with a hydrogen peroxide soluton.- chlorhexidine RATIONALE: ATI MS For central line inserton, tubing change, and line removal, place the client in the Trendelenburg’s positon if not contraindicated or in the supine positon, and instruct the client to perform the Valsalva maneuver to increase pressure in the central veins when the IV system is open. 94. A nurse is caring for a client who has hypervolemia. Which of the following is an expected assessment fnding? a. Hypotension → HYPERTENSION Weight gain→ due to the build of peripheral edema Bradycardia → TACHYCARDIA Loss of skin turgor → this happened when you’re dehydrated. RATIONALE: ATI MS 267 Hypervolemia, as there is excess fluid in the extracellular space. Other signs: peripheral edema due to an excess of fluids within the body and lungs, resultng in weight gain, distended neck veins, and increased urine output. 95. A nurse is reviewing discharge teaching with a client with a client who has a new prescripton for warfarin. Which of the following client statements indicates an understanding of the teaching? A. “I know the medicaton increases my risk for blood clots.” B. “I should avoid taking ibuprofen while taking this medicaton.” C. “I will increase green leafy vegetables in my diet.” D. “I will return in 1 month to have my blood tested.” Ratonale page 143: Warfarin is an antcoagulant. Use to prevent blood clots from getng larger or additonal clots from forming. Needs weekly blood draws, not monthly. Do not increase intake in foods high in vitamin K (green leafy vegetables). Vitamin K reduces the antcoagulant effects of warfarin. Aspirin and ibuprofen should not be used as painkillers when taking on warfarin because it increases risk for bleeding and bruising. 96. A nurse is caring for a client who has glaucoma. Which of the following fndings should the nurse expect? a. The client reports loss of peripheral vision. b. The client’s eyes are watery c. The client’s pupils are constricted. d. The client reports dark floaters in the affected eye. Ratonale: page 65. Glaucoma us a disturbance of the functonal or structural integrity of the optc nerve. Decreased fluid drainage or increased fluid secreton increases intraocular pressure (IOP) and can cause atrophic changes of the optc nerve and visual defects. Expected reference range for IOP is 10-21 mm/Hg. ● Two types of glaucoma: ○ Open-angle glaucoma: MORE COMMON. Refers to the angle between the iris and the sclera. The aqueous humor outlow is decreased due to blockages in the eye’s drainage system, causing a rise in IOP.■ Expected fndings: HA, mild eye pain, LOSS OF PERIPHERAL VISION, decreased accommodaton, halos seen around lights, elevated IOP ○ Angle-closure glaucoma: IOP rises suddenly. The angle between the iris and the sclera closes suddenly which causes the IOP to increase. NEEDS IMMEDIATE TREATMENT. ■ Expected fndings: radif onset of elevated IOP, decreased or blurred vision, colored halos seen around lights, pupils nonreactve to light, severe pain and nausea, and photophobia. 97. A nurse is planning care for a client who has lef-sided hemiplegia following a stroke. Which of the following actons should the nurse include in the plan of care? a. Remind the client to use a cane on his lef side while ambulatng. b. Provide the client with a short-handled reacher. c. Positon the bedside table on the client’s lef side. d. Place a plate guard on the client’s meal tray. Ratonale: place beside table near the patent’s bed on the unaffected side. 99. A nurse is planning to flush an implanted port for a client who is receiving chemotherapy. Which of the following supplies should the nurse plan to use? a. A short peripheral catheter b. A winged infusion needle c. A non-coring needle d. A large-bore needle Ratonale: page 166. Access with a noncoring (Huber) needle 100. A nurse is providing discharge teaching to a client who has heart failure and instructs him to limit sodium intake to 2 g per day. Which of the following statements by the client indicates an understanding of the teaching? “I can have mayonnaise on my sandwiches.” 105 mg “I can drink vegetable juice with a meal.” 141 mg “I can season my foods with garlic and onion salts.” “I can have a frozen fruit juice bar for dessert.” 4 mg 101. A nurse in the emergency department is evaluatng a young adult client for bacterial meningits. Which of the following actons should the nurse take as part of the focused assessment? A. Run tongue blade on the outside of the client’s sole and note any flaring of the toes. B. Tap the facial nerve and note any facial twitching - chvostek signs (low Ca) C. Strike the clients patellar tendon with a percussion hammer and note any increase in response D. Gently elevate the client's head and note any nuchal rigidity. Ratonale: page 31Med Surg 2016 → PRIORITY TWO (*did this one*) 1. A nurse is assessing a client who is 12hr postoperatve following a colon resecton. Which of the following fndings should the nurse report to the surgeon? a. Heart rate 90/min b. Absent bowel sounds c. Hgb 8.2 g/dl d. Gastric pH of 3.0 Ratonale: Normal Hgb is 13-18M g/dl, 12-16 g/dl. This may indicate a possible hemorrhaging. Since it is 12 hours postoperatve there might be absent bowel sounds (normal), but afer 24 hours and if there are absent bowel sounds afer drinking and eatng = should be a concern. 2. A nurse is caring for a client who has diabetes insipidus. Which of the following medicatons should the nurse plan to administer? a. Desmopressin b. Regular insulin c. Furosemide d. Lithium carbonate Ratonale: Diabetes Insipidus has decreased ADH. Administer Desmopressin/Vasopressin increase ADH and to stop patent on urinatng. 3. A nurse is admitng a client who has arthritc pain and reports taking ibuprofen several tmes daily for 3 years. Which of the following test should the nurse monitor? a. Fastng blood glucose b. Stool for occult blood c. Urine for white blood cells d. Serum calcium Ratonale: ATI Pharm 16. Pg. 485 Ibuprofen (NSAIDs) monitor for GI bleed (bloody, tarry stools, abdominal pain). 4. A nurse in the emergency department is assessing a client. Which of the following actons should the nurse take frst (Click on the “Exhibit” buton for additonal informaton about the client. There are three tabs that contain separate categories of data.) a. Obtain a sputum sample for culture b. Prepare the client for a chest x-ray c. Initate airborne precautons d. Administer ondansertron. Ratonale: No idea what the Exhibit is all about; won’t be able to answer it. 5. A nurse is contactng the provider for a client who has cancer and is experiencing breakthrough pain. Which of the following prescriptons should the nurse antcipate? a. Transmucosal fentanyl b. Intramuscular meperidine c. Oral acetaminophen d. Intravenous dexamethasone Ratonale: ATI pg. 27 Morphine sulfate and fentanyl are opioid agents used to treat moderate to severe pain. A short-actng pain medicaton is administered for breakthrough pain. 6. A nurse is admitng a client who reports chest pain and has been placed on a telemetry monitor. Which of the following should the nurse analyze to determine whether the client is experiencing a myocardial infarcton? a. PR interval b. QRS duraton c. T wave d. ST segment Ratonale: ST elevaton indicates MI. ST depression indicates ischemia7. A nurse is teaching a client who has ovarian cancer about skin care following radiaton treatment. Which of the following instructons should the nurse include? a. Pat the skin on the radiaton site to dry it b. Apply OTC moisturizer to the radiaton site c. Cover the radiaton site loosely with a gauze wrap before dressing d. Use a sof washcloth to clean the area around the radiaton site Ratonale: pg. 584. Dry the area thoroughly using patng motons. 8. A nurse is caring for a client who is receiving a blood transfusion. The nurse observes that the client has bounding peripheral pulses, hypertension, and distended jugular veins. The nurse should antcipate administering which of the following prescribed medicatons? a. Diphenhydramine b. Acetaminophen c. Pantoprazole d. Furosemide Ratonale: S/S may indicate fluid retenton or heart failure. It is important to administer diuretcs to prevent cardiovascular/respiratory distress. 9. A nurse is assessing a client who is receiving magnesium sulfate IV for the treatment of hypomagnesemia. Which of the following fndings indicates effectveness of the medicaton? a. Lungs clear b. Apical pulse 82/min c. Hyperactve bowel sounds d. Blood pressure 90/50 mm Hg Ratonale: pg. 278 Confrmed on answer sheet 10. A nurse is reviewing a client’s ABG results pH 7.42, PaC02 30 mm Hg, and HCO3 21 mEq/L. The nurse should recognize these fndings as indicaton of which of the following conditons? a. Metabolic acidosis b. Metabolic alkalosis c. Compensated respiratory alkalosis d. Uncompensated respiratory acidosis Ratonale: because the HCO3 21 trying to compensate for respiratory alkalosis. 11. A nurse is caring for a client who has a deep partal thickness burns over 15% of her body which of the following labs should the nurse expect during the frst 24 hours? A. Decreased BUN (elevated due to fluid loss) B. Hypoglycemia (High due to stress) C. Hypoalbuminemia (Low due to fluid loss) D. Decreased Hematocrit (Elevated due to 3rd spacing during resuscitaton phase) Ratonale: Pg. 481 ATI. Total protein and albumin- low due to fluid loss. 12. A nurse is caring for a client who has dumping syndrome following a gastrectomy, which of the following actons should the nurse takes? a. Offer the client high carbohydrate meal optons (High fat, high protein, low fber, low to moderate carbs page 317, chapter 49 Peptc ulcer disease med surge ATI PDF 10.0) b. Provide the client with four full meals a day (Small frequent meals) c. Encourage the client to drink at least 360 ml of fluids with meals (Eliminate liquids with meals for 1 hr. prior and following a meal) d. Have the client lie down for 30 minutes afer meals (Lying down afer a meal slows the movement of food within the intestnes) Ratonale: ATI pg. 318 Dumping syndromes is a term that refers to a constellaton of vasomotor symptoms that occurs afer eatng, especially following a Billroth II procedure. Early manifestatons usually occur within 30 minutes of eatng and include vertgo, tachycardia, syncope, sweatng, pallor, palpitatons, and the desire to lie down. The nurse should instruct the client to decrease the amount of fluid taken at meals and to avoid high-carbohydrate foods, including fluids such as fruit nectars; to assume a low-Fowler's positon during meals; to lie down for 30 minutes afer eatng to delay gastric emptying; and to take antspasmodics as prescribed.12. A nurse is teaching a group of young adult clients about risk factors for hearing loss. Which of the following factors should the nurse include in the teaching? a. Born with a high weight b. Chronic infectons of the middle ear c. Use a loop diuretc diuretc such as furosemide and antbiotcs like aminoglycoside and gentamicin leads to ototoxic medicaton d. Perforaton of the ear drum e. Frequent exposure to low volume noise Ratonale: Pedia ATI pg. 77 Exposure to loud environmental sounds. Hearing defects can be caused by a variety of conditons, including anatomic malformaton, maternal ingeston of toxic substances during pregnancy, perinatal asphyxia, perinatal infecton, chronic ear infecton, and ototoxic medicatons. 13. A nurse is preparing to administer fresh frozen plasma to a client. Which of the following actons should the nurse take? a. Administer the plasma immediately afer thawing b. Transfuse the plasma over 4 hour (Can be in 2 to 4 hours) c. Hold the transfusion if the client is actvely bleeding (YOU HAVE TO GIVE IT. That’s the whole point! The patent is losing blood so you have to replace it. We give fresh frozen plasma because he or she may have clotng defciencies) d. Administer the transfusion through a 24 gauge saline lock (Has to be a 18 or 20 gauge) Ratonale: Saunders pg. 164 Fresh-frozen plasma 1. Fresh-frozen plasma may be used to provide clotng factors or volume expansion; it contains no platelets. 2. Fresh-frozen plasma is infused within 2 hours of thawing, while clotng factors are stll viable, and is infused over a period of 15 to 30 minutes. 3. Rh compatbility and ABO compatbility are required for the transfusion of plasma products. 4. Evaluaton of an effectve response is assessed by monitoring coagulaton studies, partcularly the prothrombin tme and the partal thromboplastn tme, and resoluton of hypovolemia. 14. A nurse is assessing a client who reports numbness and tngling of his toes and exhibits a positve TROUSSEAU. Which of the following electrolyte imbalance should the nurse suspect? a. Hyponatremia b. Hyperchloremia c. Hypermagnesemia d. Hypocalcemia Ratonale: (ch 44 page 277 MS ATI PDF 10.0) Positve s/s of CHvostek’s or Trousseau sign indicates HYPOCALCEMIA. 15. A home health nurse is teaching a client how to care for a peripherally central catheter in his right arm. Which of the following statements should the nurse include in the teaching? a. Change the transparent dressing over the inserton site every 48 hours - transparent dressing can be up to 7 days b. Clean the inserton site with mild soap and water - when showering, must inserton site must be covered!!!!! No water can be in it. c. Measure your right arm circumference once weekly- does not say in the chapter d. Use a 10 milliliter syringe when flushing the catheter Ratonale: (Chapter 27 cardiovascular diagnostcs and therapeutc procedures p. 166 MS ATI PDF 10.0) Use transparent dressing to allow for visualizaton. Follow facility protocol for dressing changes, usually every 7 days and when indicated (wet, loose, soiled). Shower, cover dressing site to avoid water exposure. Follow the Infusion Nurses Society (INS) practce recommendatons for flushing. Use a 10 mL syringe for flushing the PICC line. Do not apply force if resistance is met. 16. A nurse is caring for a client who has a central venous access device. Which of the following assessment fndings should the nurse report to the provider? a. RBC count of 4.7 million/mm (4.5-5.3M; 4.1-5.1) b. BUN 22-mg/ dl – (5-25 mg/dl) 10-20c. WBC count of 16,000/ mm 3 à Elevated; phlebits is a complicaton; infecton is a complicaton that can happen 7 days afer inserton, also temp increase if 1 degree can happen (5,000-10,000) d. Blood glucose of 120 mg/dl (70-110) Ratonale: (P.166 MS ATI PDF 10.0) 17. A nurse is providing dietary teaching to a client who has chronic kidney disease and a decreased glomerular fltraton rate. Which of the following statements by the client indicates an understanding of the teaching? a. I will spread my protein allowances over the entre day b. I should increase my intake of canned salmon to three tmes per week (NO SODIUM) c. I will season my food with lemon pepper rather than salt (We do not want to give the dietary sodium, potassium, phosphorus, and magnesium. I don’t know what lemon pepper has, but we want to RESTRICT sodium, potassium, phosphorus and magnesium.) d. I should limit my intake of hard cheese to 3 ounces each day (NO SODIUM) Ratonale: (p.382 chapter 59) Ratonale: ATI MS pg. 382-control protein intake based on the client’s stage of CKD and type of dialysis. Restrict sodium intake to prevent fluid retenton and hypertension Low GFR indicates CRD. 18. A nurse is caring for a client who has a peripherally inserted central catheter. The client is receiving an antbiotc via intermitent IV bolus. Which of the following actons should the nurse take? a. Administer 20 ml of 0.9 sodium chloride afer each dose of medicaton à (you only flush with 10 ml of NS, not 20. 20 is for flushing blood) b. Flush the catheter using a 5 ml syringe à you use a 10mL syringe to flush c. Verify the placement with an x-ray prior to the inital dose (POSTPROCEDURE) d. Change the transparent membranes dressing daily (dressing can last for up to 7 days) Ratonale: (PAGE 166 ch 27 MS ATI PDF 10.0 19. A nurse is teaching a client using a metered dose rescue inhaler. Which of the following statements should the nurse include in the teaching? a. Do not shake your inhaler before use à shake 5-6x. b. Exhale fully before bringing the inhaler to your lips c. Depress the canister afer you inhale (depress the inhaler as the patent inhales to go in the lungs). d. Use peroxide to clean the mouthpiece if your inhaler (mild soap and water) Ratonale: Pharm ATI pg. 7 Review TABLE for administraton of MDI. For an MDI, instruct the client to: ».Remove cap from inhaler. ».Shake inhaler fve to six tmes. ».Hold inhaler with mouthpiece at the botom. ».Hold inhaler with thumb near mouthpiece and index and middle fngers at top. ».Hold inhaler approximately 2 to 4 cm (1 to 2 in) away from front of mouth. ».Take a deep breath, and then exhale. ».Tilt head back slightly, and press inhaler. While pressing inhaler, begin a slow, deep breath that should last for 3 to 5 seconds to facilitate delivery to the air passages. ».Hold breath for 10 seconds to allow medicaton to deposit in airways. ».Take inhaler out of mouth, and slowly exhale through pursed lips. ».Resume normal breathing. 20. A nurse is assessing the pain status of a group of clients. Which of the following fndings indicate a client is experiencing referred pain? a. A client who has angina reports substernal chest pain b. A client who has pancreatts reports pain in the lef shoulder à referred pain is pain that is felt in another place that is not in the same area as where the pain should be felt. Pain radiates on a certain locaton of the body. c. A client who is postoperatve reports incisional pain d. A client who has peritonits reports generalized abdominal pain Ratonale: ATI MS (page 30) Visceral: in internal organs such as the stomach or intestnes. It can cause referred pain in other body locatons separate from the stmulus.21. A nurse is caring for a client who has just returned from surgery with an external fxator to the lef tbia. Which of the following assessments fndings requires immediate interventon by the nurse? a. The client reports a pain level of 7 on a scale from 0 -10 at the operatve site. (The patent just came from surgery so pain is normal for post op patents for frst couple of hours.) b. The client’s capillary refll in the lef toe is 6 seconds signs and symptoms of compartment syndrome à ABCs are compromised. (Cap refll should be below 3 seconds. This is s/s for compartment syndrome. Untreated can lead to necrosis.) c. The client has an oral temperature of 38.3 (100.9 F) (I wouldn’t pick this because i always see temp 101 as a priority from previous ratonales with other ats.) d. The client has 100 ml of blood in the closed sucton drained. (I believe this is normal for post-op patents.) Ratonale: (p .456 MS ATI PDF 10.0 chapter 71) Assess 5 P’s: pain, paralysis, paresthesia, pallor, pulselessness 22. A nurse is assessing a client who has acute pancreatts and has been receiving total parenteral nutriton for the past 72 hours. Which of the following fndings requires the nurse to intervene? a. Right upper quadrant pain (patent has acute pancreatts, so it’s normal) b. Capillary blood glucose level of 164 mg/dl - glucose not signifcantly high c. WBC counts 13,000/mm3 (Infecton is one complicaton of TPN administraton d. Crackle in bilateral lower lobes (Priority, FVE/fluid shifs to the lungs may lead to respiratory distress/collapse/failure) life threatening than infecton. May need to decrease ml/hr and assess. Ratonale: (chapter 47 page 299 MS ATI PDF 10.0) (ABC’s compromised, also one of the complicatons of TPN is fluid imbalance aka fluid volume excess.) 23. A nurse is caring for a client who has hypotension, cool and clammy skin, tachycardia, and tachypnea. In which of the following positons should the nurse place the client? a. Reverse Trendelenburg (page 232 says for hypotension patents must be flat with legs elevated to increase venous return.) b. Side Lying c. High Fowlers d. Feet elevated Ratonale: Manifestatons of Heart failure/Cardiogenic Shock Pg. 195. Chapter 31 MS ATI PDF 10.0) 24. A nurse is caring for a client who has tuberculosis and is taking rifampin. The client reports that her saliva has turned redorange in color. Which of the following responses should the nurse make? a.) “This fnding may indicate possible medicaton toxicity” b.) “Your provider will prescribe a different medicaton regimen” c.) “This is an expected adverse effect of this medicaton.” d.) “You will need to increase your fluid intake to resolve this problem” Ratonale: pg. 137 ATI MS Expected to be orange in rifampin: urine/secretons 25. A nurse is preparing to administer a unit of packed RBCs for a client who is receiving a contnuous IV infusion of 5% dextrose in water. Which of the following actons should the nurse take? a.) Administer the unit through secondary IV tubing (Y-ports) b.) Verify the blood product with assistve personnel (another RN) c.) Begin an IV infusion of 0.9% sodium chloride d.) Insert another 22-gauge IV catheter (18-20 gauge is recommended. 22 is too small) Ratonale: ATI Pharm pg. 355 Insert an intravenous (IV) line and infuse normal saline; maintain the infusion at a keep-vein-open rate. An 18- or 19-gauge IV needle will be needed to achieve a maximum flow rate of blood products and to prevent damage to red blood cells; if a smaller gauge needle must be used, red blood cells may be diluted with normal saline (check agency procedure). Use only 0.9% sodium chloride soluton to administer with blood products; prime IV and blood tubing with this soluton. Use a blood flter for most blood products and either a Y-type or straight tubing set depending on facility policy. 26. A nurse is planning care for a client who is 12 hr. postoperatve following a kidney transplant. Which of the following actons should the nurse include in the plan of care? a.) Check the client’s blood pressures every 8 hr. b.) Administer opioids PO c.) Assess urine output hourly ---à prevent shock and mods d.) Monitor for hypokalemia as a manifestaton of acute rejecton Ratonale: Pg. 37428. A nurse is obtaining a medicaton history from a client who is to start therapy with naproxen for rheumatoid arthrits. Which of the following medicatons places the client at risk for bleeding? a.) Captopril –ace inhibitor b.) Ibuprofen --NSAIDS c.) Digoxinà antdysrhythmic d.) Phenytoin-seizure 30. A nurse is assessing the extremites of a client who has Raynaud’s disease. Which of the following fndings should the nurse expect? a.) Blanching of the hands à REYNAUD PHENOMENON b.) Hyperactve reflexes c.) Calf pain with foot dorsiflexion d.) Vitligo on affected extremites Ratonale: (P 558 at MD pdf 10.0) Epiosodic vasospasm in the small peripheral arteries and arterioles, precipitated by exposure to cold or stress usually affects the hands or less ofen the feet. CREST Calcinosis- calcium deposits in the skin Raynaud phenomenon- spasm of blood vessels in response to cold or stress Esophageal dysfuncton- acid reflux and decease in mortlity of esophagus Scierodactyly- thickening and tghtening of the skin on the fngers and hands Telangiectasias- dilaton of capillaries causing red marks on surface of skin. 31. A nurse is caring for a group of clients. The nurse should obtain a blood pressure reading using only the lef extremity from which of the following clients? a. A client who has a peripherally inserted central catheter in the lef arm b. A client who has lef-sided Bell’s palsy c. A client who has a right upper extremity arteriovenous fstula (always use opposite arm from an AV fstula) d. A client who has right-sided weakness due to Parkinson’s disease 32. A nurse is providing teaching to a client who has DVT. Which of the following fndings should the nurse identfy as a risk factor for the development of DVTs? a. Hypertension b. Cirrhosis c. NSAIDS use d. Oral Contraceptve Use Ratonale: page 141 of ATI Book 2016 33. A nurse is caring for client who has Cushing’s disease. Which of the following actons should the nurse takes frst? (Click Exhibit buton for additonal informaton) a. Check the client’s medicaton administraton record for anthypertensive medicaton. b. Verify the client’s understanding of sodium restricton. c. Auscultate the client’s lung sound -à due to fluid retenton; acton frst varies on the exhibit d. Determine the need for further glucose monitoring Ratonale: cushings disease:increase in cortsol. Hyperglycemia, obesity, striae, moon round face, osteoporosis, buffalo hump, gynecomasta, bruise easily, fluid retenton, hypertension 34. A nurse is assessing a client who has nephrotc syndrome. Which of the fndings should the nurse expect? a. Proteinuria b. Flank pain c. Hyperalbuminemia d. HypotensionRatonale: Lewis book page 1075. Clinical manifestaton of N.S.: peripheral edema, massive proteinuria, HTN, hyperlipidemia, and hypoalbuminemia. 35. A nurse is assessing a client who has right-sided heart failure. Which of the following assessment fndings should the nurse expect to fnd? a. Oliguria (Lef) b. S3/S4 galloping heart sounds (Lef) c. Poor skin turgor d. Pitng edema Ratonale: Page 198 Chapter 32 of ATI Book. Additonal source pg. 363 36. A nurse is caring for a client who has newly inserted chest tube. The nurse should clarify which of the following prescriptons with the provider? a. Notfy the provider when tdaling ceases. (Yes notfy) b. Assistng the client out of bed three tmes daily. c. Vigorously strip the chest tube twice daily. (Vigorously and BID) d. Administer morphine 2 mg IV bolus every 3 hr PRN for pain. (Don’t need to clarify) Ratonale: Page 104 chapter 18 of ATI Book it says that: “Do not strip or milk tubing; only perform when prescribed. Stripping creates a high negatve pressure and can damage lung tssue. Stripping tube of clots 37. A nurse is teaching a client who is taking an ACE inhibitor for heart failure. Which of the following instructons should the nurse include for home management of heart failure? a. Obtain daily weight. b. Use of salt substtute. (Avoid it) c. Monitor Intake and Output d. Limit daily actvity. Ratonale: Pg 199 ATI Book. 38. A nurse is providing discharge teaching to a client who has a permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching? a. I need to maintain pressure over the pacemaker site with an elastc bandage. b. I need to check my pulse rate every day for a full minute. c. The pacemaker will deliver shock if I develop a dysrhythmia d. When a microwave oven is in use, I need to stay out of the ro