Med Surg 2 Final ATI book
A nurse is caring for a client who has chronic venous insufficiency and a prescription for thigh
high compression stockings. Which action should the nurse take?
a. elevate legs for 10 min, 2-3 times a day while wearing stockings
b. apply the stockings in the morning upon awakening and before getting out of bed
c. roll the stockings down to the knees to relieve discomfort on the legs
d. remove the stockings while out of bed for 1 hour, 4 times a day, to allow the legs to rest -
ANSB. Applying the stockings in the morning upon waking up before getting out of bed reduces
venous stasis and assists in the venous return of blood to the heart.
A nurse is assessing a client who has PAD. Which of the following should the nurse expect?
a. edema around ankles and feet
b. ulceration around the medial malleoli
c. scaling edema of the lower legs with stasis dermatitis
d. pallor on elevation of the limbs, and rubber when the limbs are dependent - ANSD. In a client
who has PAD, pallor is seen in the extremities when the limbs are elevated, and rubor occurs
when they are lowered
A nurse is teaching a client who has a new diagnosis of severe peripheral arterial disease.
Which should the nurse include?
a. Wear tightly fitting insulated socks with shoes when going outside
b. elevate both legs above heart when resting
c. apply a heating pad to both legs for comfort
d. place both legs in dependent position while sleeping - ANSD. Such as hanging off of the bed.
This can alleviate swelling and discomfort of the legs
A nurse is teaching a client who has a new prescription for clopidogrel. Select all that the nurse
should include.
a. avoid consumption of grapefruit
b. monitor black and tarry stools
c. take this when you have pain
d. schedule weekly PT test
e. Limit food sources containing vit. K while taking this - ANSA, B
A nurse is caring for a client who has a DVT and has been taking heparin for a week. Two days
ago, the provider also prescribed warfarin. The client asks the nurse about receiving both at the
same time. What should the nurse say?
a. I will remind your provider that you are already receiving heparin
b. your lab findings indicate that 2 anticoagulants are needed
c. it takes 3-4 days for the therapeutic effects of warfarin, and then heparin can be discontinued
,d. only one of these medications are being given to treat your DVT - ANSC. warfarin depresses
synthesis of clotting factors but does not have an effect on clotting factors that are present. It
takes 3-4 days for the clotting factors that are present to decay and for the therapeutic effects of
warfarin to occur.
A nurse in an outpatient clinic is assessing a client who reports night sweats and fatigue. He
states he had a cough along with nausea and diarrhea. His temperature is 38.1 C orally. The
client is afraid he has HIV. Which action should the nurse take? Select all that apply.
a. perform a physical assessment
b. determine when s/s began
c. teach the client about HIV transmission
d. draw blood for HIV testing
e. obtain a sexual history - ANSa, b, e
a nurse is caring for a client who is suspected of having HIV. The nurse should identify that
which of the following DX tests and lab values are used to confirm HIV infection? Select all that
apply.
a. western blot
b. Indirect immunofluorescence assay
c. CD4+ T-lymphocyte count
d. HIV RNA quantification test
e. CSF analysis - ANSa, b
a nurse is providing teaching for a client who has stage 3 HIV disease. Which of the following
statements by the client should indicate to the nurse an understanding of the teaching?
a. I will wear gloves while changing the kitty litter
b. I will rinse raw fruits with water before eating them
c. I will wear a mask when around family members who are ill
d. I will cook vegetables before eating them - ANSD, no raw fruits/veggies
A nurse is assessing a client for HIV. Which are risk factors? Select all that apply.
a. perinatal exposure
b. pregnancy
c. monogamous sex partner
d. older woman adult
e. occupational exposure - ANSA, D, E
A nurse is providing teaching for a client who has stage 2 HIV and is having difficulty
maintaining a normal weight. Which of the following statements by the client should indicate to
the nurse an understanding of the teaching?
a. I will choose to diet high in fat to help gain weight
b. I will be sure to eat 3 large meals a day
c. I will drink up to 1 liter of fluid a day
, d. I will add high-protein foods to my diet - ANSD. high protein and high calorie is the best way
to gain weight and maintain health
Which instruction should the nurse discuss with the client diagnosed with Raynaud's
phenomenon?
1.Explain exacerbations will not occur in the summer.
2. Use nicotine gum to help quit smoking.
3.Wear extra-warm clothing during cold exposure.
4.Avoid prolonged exposure to direct sunlight. - ANS3. Raynaud's phenomenon is a form of
intermittent arteriolar vasoconstriction that results in coldness, pain, and pallor of fingertips or
toes; therefore, the client should keep warm to prevent vasoconstriction of the extremities.
The nurse is teaching the client with peripheral vascular disease. Which interventions should the
nurse discuss with the client? Select all that apply.
1.Wash your feet in antimicrobial soap.
2.Wear comfortable, well-fitting shoes
3.Cut your toenails in an arch.
4.Keep the area between the toes dry.
5.Use a heating pad when feet are cold. - ANS2.Shoes must be comfortable to prevent blisters
or ulcerations of the feet.
4.Moisture between the toes increases fungal growth, leading to skin breakdown.
The nurse is caring for clients on a medical floor. Which client will the nurse assess first?
1.The client with an abdominal aortic aneurysm who is constipated.
2.The client on bedrest who ambulated to the bathroom.
3.The client with essential hypertension who has epistaxis and a headache
4.The client with arterial occlusive disease who has a decreased pedal pulse. - ANS3. A bloody
nose and a headache indicate the client is experiencing very high blood pressure and should be
assessed first because of a possible myocardial infarction or stroke.
The client with peripheral venous disease is scheduled to go to the whirlpool for a dressing
change. Which is the nurse's priority intervention?
1.Escort the client to the physical therapy department.
2.Medicate the client 30 minutes before going to the whirlpool.
3.Obtain the sterile dressing supplies for the client
4.Assist the client to the bathroom prior to the treatment. - ANS2. The client's pain is priority,
and the nurse should premedicate prior to treatment.
The client is receiving prophylactic low molecular weight heparin. There are no PT/PTT or INR
results on the client's chart since admission three (3) days ago. Which action should the nurse
implement?
1.Administer the medication as ordered.
2.Notify the health-care provider immediately.
A nurse is caring for a client who has chronic venous insufficiency and a prescription for thigh
high compression stockings. Which action should the nurse take?
a. elevate legs for 10 min, 2-3 times a day while wearing stockings
b. apply the stockings in the morning upon awakening and before getting out of bed
c. roll the stockings down to the knees to relieve discomfort on the legs
d. remove the stockings while out of bed for 1 hour, 4 times a day, to allow the legs to rest -
ANSB. Applying the stockings in the morning upon waking up before getting out of bed reduces
venous stasis and assists in the venous return of blood to the heart.
A nurse is assessing a client who has PAD. Which of the following should the nurse expect?
a. edema around ankles and feet
b. ulceration around the medial malleoli
c. scaling edema of the lower legs with stasis dermatitis
d. pallor on elevation of the limbs, and rubber when the limbs are dependent - ANSD. In a client
who has PAD, pallor is seen in the extremities when the limbs are elevated, and rubor occurs
when they are lowered
A nurse is teaching a client who has a new diagnosis of severe peripheral arterial disease.
Which should the nurse include?
a. Wear tightly fitting insulated socks with shoes when going outside
b. elevate both legs above heart when resting
c. apply a heating pad to both legs for comfort
d. place both legs in dependent position while sleeping - ANSD. Such as hanging off of the bed.
This can alleviate swelling and discomfort of the legs
A nurse is teaching a client who has a new prescription for clopidogrel. Select all that the nurse
should include.
a. avoid consumption of grapefruit
b. monitor black and tarry stools
c. take this when you have pain
d. schedule weekly PT test
e. Limit food sources containing vit. K while taking this - ANSA, B
A nurse is caring for a client who has a DVT and has been taking heparin for a week. Two days
ago, the provider also prescribed warfarin. The client asks the nurse about receiving both at the
same time. What should the nurse say?
a. I will remind your provider that you are already receiving heparin
b. your lab findings indicate that 2 anticoagulants are needed
c. it takes 3-4 days for the therapeutic effects of warfarin, and then heparin can be discontinued
,d. only one of these medications are being given to treat your DVT - ANSC. warfarin depresses
synthesis of clotting factors but does not have an effect on clotting factors that are present. It
takes 3-4 days for the clotting factors that are present to decay and for the therapeutic effects of
warfarin to occur.
A nurse in an outpatient clinic is assessing a client who reports night sweats and fatigue. He
states he had a cough along with nausea and diarrhea. His temperature is 38.1 C orally. The
client is afraid he has HIV. Which action should the nurse take? Select all that apply.
a. perform a physical assessment
b. determine when s/s began
c. teach the client about HIV transmission
d. draw blood for HIV testing
e. obtain a sexual history - ANSa, b, e
a nurse is caring for a client who is suspected of having HIV. The nurse should identify that
which of the following DX tests and lab values are used to confirm HIV infection? Select all that
apply.
a. western blot
b. Indirect immunofluorescence assay
c. CD4+ T-lymphocyte count
d. HIV RNA quantification test
e. CSF analysis - ANSa, b
a nurse is providing teaching for a client who has stage 3 HIV disease. Which of the following
statements by the client should indicate to the nurse an understanding of the teaching?
a. I will wear gloves while changing the kitty litter
b. I will rinse raw fruits with water before eating them
c. I will wear a mask when around family members who are ill
d. I will cook vegetables before eating them - ANSD, no raw fruits/veggies
A nurse is assessing a client for HIV. Which are risk factors? Select all that apply.
a. perinatal exposure
b. pregnancy
c. monogamous sex partner
d. older woman adult
e. occupational exposure - ANSA, D, E
A nurse is providing teaching for a client who has stage 2 HIV and is having difficulty
maintaining a normal weight. Which of the following statements by the client should indicate to
the nurse an understanding of the teaching?
a. I will choose to diet high in fat to help gain weight
b. I will be sure to eat 3 large meals a day
c. I will drink up to 1 liter of fluid a day
, d. I will add high-protein foods to my diet - ANSD. high protein and high calorie is the best way
to gain weight and maintain health
Which instruction should the nurse discuss with the client diagnosed with Raynaud's
phenomenon?
1.Explain exacerbations will not occur in the summer.
2. Use nicotine gum to help quit smoking.
3.Wear extra-warm clothing during cold exposure.
4.Avoid prolonged exposure to direct sunlight. - ANS3. Raynaud's phenomenon is a form of
intermittent arteriolar vasoconstriction that results in coldness, pain, and pallor of fingertips or
toes; therefore, the client should keep warm to prevent vasoconstriction of the extremities.
The nurse is teaching the client with peripheral vascular disease. Which interventions should the
nurse discuss with the client? Select all that apply.
1.Wash your feet in antimicrobial soap.
2.Wear comfortable, well-fitting shoes
3.Cut your toenails in an arch.
4.Keep the area between the toes dry.
5.Use a heating pad when feet are cold. - ANS2.Shoes must be comfortable to prevent blisters
or ulcerations of the feet.
4.Moisture between the toes increases fungal growth, leading to skin breakdown.
The nurse is caring for clients on a medical floor. Which client will the nurse assess first?
1.The client with an abdominal aortic aneurysm who is constipated.
2.The client on bedrest who ambulated to the bathroom.
3.The client with essential hypertension who has epistaxis and a headache
4.The client with arterial occlusive disease who has a decreased pedal pulse. - ANS3. A bloody
nose and a headache indicate the client is experiencing very high blood pressure and should be
assessed first because of a possible myocardial infarction or stroke.
The client with peripheral venous disease is scheduled to go to the whirlpool for a dressing
change. Which is the nurse's priority intervention?
1.Escort the client to the physical therapy department.
2.Medicate the client 30 minutes before going to the whirlpool.
3.Obtain the sterile dressing supplies for the client
4.Assist the client to the bathroom prior to the treatment. - ANS2. The client's pain is priority,
and the nurse should premedicate prior to treatment.
The client is receiving prophylactic low molecular weight heparin. There are no PT/PTT or INR
results on the client's chart since admission three (3) days ago. Which action should the nurse
implement?
1.Administer the medication as ordered.
2.Notify the health-care provider immediately.
