ATI ADULT MEDICAL SURGICAL 2019
A nurse is caring for a client who is 24 hr postoperative following a total hip arthroplasty. Which
of the following actions should the nurse take?
A)Place the affected leg in external rotation.
B)Encourage the client to use the incentive spirometer every shift.
C)Instruct the client to lean forward when rising from a chair.
D)Maintain abduction of the affected extremity. - ANSD)Maintain abduction of the affected
extremity.
The nurse should ensure that the affected extremity is in a position of
abduction to prevent hip dislocation. The nurse should place an abductor
pillow or several pillows between the client's legs to keep the affected
extremity in abduction while the client is in bed.
A nurse is providing teaching to a client who is scheduled for a bronchoscopy. Which of the
following statements should the nurse include in the teaching?
A)"You will not be able to eat or drink after the procedure until you are able to cough."
B)"You will drink a contrast solution 30 minutes prior to the procedure."
C)"The purpose of this procedure is to remove excess fluid from your lungs."
D)"You will need to lie on your back for 4 to 6 hours following the procedure." - ANSA)"You will
not be able to eat or drink after the procedure until you are able to cough."
A client who had a bronchoscopy received a local anesthetic that can
suppress the cough reflex. The cough reflex protects the client from
aspirating fluids or food. Therefore, the client should not eat or drink until the
cough reflex returns.
A nurse is assessing a client's understanding of a surgical procedure prior to witnessing their
signature on the informed consent form. The nurse determines that the client does not
understand what the procedure will involve. Which of the following actions should the nurse
take?
A)Provide teaching about the surgical procedure for the client.
B)Instruct the client's spouse to sign the consent form.
C)Read the consent form to the client using words the client will understand.
D)Contact the provider who will be performing the procedure. - ANSD)Contact the provider who
will be performing the procedure.
The nurse should advocate for the client by informing the provider if the
client does not understand the procedure. It is the responsibility of the
provider to discuss the procedure more fully with the client.
A nurse is providing discharge teaching to a client who has COPD. Which of the following
instructions should the nurse include in the teaching?
A)"Schedule controlled coughing exercises after meals."
, B)"Consume a diet that is high in calories."
C)"Practice breath-holding."
D)"Perform arm-reaching exercises." - ANSB)"Consume a diet that is high in calories."
Dyspnea decreases energy available for eating. Therefore, the nurse should
encourage the client to eat soft, high-calorie and high-protein foods to
prevent weight loss.
A nurse is providing teaching about dietary options for a client who has cholelithiasis. Which of
the following statements should the nurse include in the teaching?
A)"Cauliflower is a good dietary choice."
B)"Increase the amount of egg yolks in your diet."
C)"Select desserts such as angel food cake."
D)"Eat choice or prime cuts of meat." - ANSA)"Cauliflower is a good dietary choice."
The nurse should instruct the client to avoid foods that are gas-forming, such as cauliflower and
cabbage. These foods can increase the client's abdominal
discomfort.
A nurse is preparing to administer potassium chloride 10 mEq IV over 1 hr to a client. Available
is potassium chloride 10 mEq in 100 mL of 0.9% sodium chloride. The nurse should set the
infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number.
Use a leading zero if it applies. Do not use a trailing zero.) - ANS100 mL/hr
A nurse is monitoring a client who has a traumatic brain injury. Which of the following findings
should the nurse identify as a manifestation of Cushing's triad?
A)Increase in temperature from 37.5. C (99.5. F) to 38.3. C (101. F)
B)Increase in blood pressure from 130/80 mm Hg to 180/100 mm Hg
C)Increase in urine output from 30 mL/hr to 100 mL/hr
D)Increase in heart rate from 70/min to 90/min - ANSB)Increase in blood pressure from 130/80
mm Hg to 180/100 mm Hg
A change in blood pressure from 130/80 mm Hg to 180/100 mm Hg indicates
a widened pulse pressure and hypertension, which are components of
Cushing's triad, a sign of increased intracranial pressure.
A nurse is teaching a client who has a new diagnosis of type 1 diabetes mellitus. Which of the
following statements by the client indicates an understanding of the teaching?
A)"I am aware that my diabetes is caused by an autoimmune disorder."
B)"I know that my diabetes developed slowly over several years."
C)"If I lose weight, I may be able to stop taking insulin."
D)"I have developed a resistance to insulin." - ANSD)"I have developed a resistance to insulin."
Type 1 diabetes mellitus involves pancreatic beta cell destruction, resulting
in the inability of the pancreas to produce insulin. Type 2 diabetes mellitus is
caused by insulin resistance, which develops from obesity and physical
inactivity.
A nurse is caring for a client who is 24 hr postoperative following a total hip arthroplasty. Which
of the following actions should the nurse take?
A)Place the affected leg in external rotation.
B)Encourage the client to use the incentive spirometer every shift.
C)Instruct the client to lean forward when rising from a chair.
D)Maintain abduction of the affected extremity. - ANSD)Maintain abduction of the affected
extremity.
The nurse should ensure that the affected extremity is in a position of
abduction to prevent hip dislocation. The nurse should place an abductor
pillow or several pillows between the client's legs to keep the affected
extremity in abduction while the client is in bed.
A nurse is providing teaching to a client who is scheduled for a bronchoscopy. Which of the
following statements should the nurse include in the teaching?
A)"You will not be able to eat or drink after the procedure until you are able to cough."
B)"You will drink a contrast solution 30 minutes prior to the procedure."
C)"The purpose of this procedure is to remove excess fluid from your lungs."
D)"You will need to lie on your back for 4 to 6 hours following the procedure." - ANSA)"You will
not be able to eat or drink after the procedure until you are able to cough."
A client who had a bronchoscopy received a local anesthetic that can
suppress the cough reflex. The cough reflex protects the client from
aspirating fluids or food. Therefore, the client should not eat or drink until the
cough reflex returns.
A nurse is assessing a client's understanding of a surgical procedure prior to witnessing their
signature on the informed consent form. The nurse determines that the client does not
understand what the procedure will involve. Which of the following actions should the nurse
take?
A)Provide teaching about the surgical procedure for the client.
B)Instruct the client's spouse to sign the consent form.
C)Read the consent form to the client using words the client will understand.
D)Contact the provider who will be performing the procedure. - ANSD)Contact the provider who
will be performing the procedure.
The nurse should advocate for the client by informing the provider if the
client does not understand the procedure. It is the responsibility of the
provider to discuss the procedure more fully with the client.
A nurse is providing discharge teaching to a client who has COPD. Which of the following
instructions should the nurse include in the teaching?
A)"Schedule controlled coughing exercises after meals."
, B)"Consume a diet that is high in calories."
C)"Practice breath-holding."
D)"Perform arm-reaching exercises." - ANSB)"Consume a diet that is high in calories."
Dyspnea decreases energy available for eating. Therefore, the nurse should
encourage the client to eat soft, high-calorie and high-protein foods to
prevent weight loss.
A nurse is providing teaching about dietary options for a client who has cholelithiasis. Which of
the following statements should the nurse include in the teaching?
A)"Cauliflower is a good dietary choice."
B)"Increase the amount of egg yolks in your diet."
C)"Select desserts such as angel food cake."
D)"Eat choice or prime cuts of meat." - ANSA)"Cauliflower is a good dietary choice."
The nurse should instruct the client to avoid foods that are gas-forming, such as cauliflower and
cabbage. These foods can increase the client's abdominal
discomfort.
A nurse is preparing to administer potassium chloride 10 mEq IV over 1 hr to a client. Available
is potassium chloride 10 mEq in 100 mL of 0.9% sodium chloride. The nurse should set the
infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number.
Use a leading zero if it applies. Do not use a trailing zero.) - ANS100 mL/hr
A nurse is monitoring a client who has a traumatic brain injury. Which of the following findings
should the nurse identify as a manifestation of Cushing's triad?
A)Increase in temperature from 37.5. C (99.5. F) to 38.3. C (101. F)
B)Increase in blood pressure from 130/80 mm Hg to 180/100 mm Hg
C)Increase in urine output from 30 mL/hr to 100 mL/hr
D)Increase in heart rate from 70/min to 90/min - ANSB)Increase in blood pressure from 130/80
mm Hg to 180/100 mm Hg
A change in blood pressure from 130/80 mm Hg to 180/100 mm Hg indicates
a widened pulse pressure and hypertension, which are components of
Cushing's triad, a sign of increased intracranial pressure.
A nurse is teaching a client who has a new diagnosis of type 1 diabetes mellitus. Which of the
following statements by the client indicates an understanding of the teaching?
A)"I am aware that my diabetes is caused by an autoimmune disorder."
B)"I know that my diabetes developed slowly over several years."
C)"If I lose weight, I may be able to stop taking insulin."
D)"I have developed a resistance to insulin." - ANSD)"I have developed a resistance to insulin."
Type 1 diabetes mellitus involves pancreatic beta cell destruction, resulting
in the inability of the pancreas to produce insulin. Type 2 diabetes mellitus is
caused by insulin resistance, which develops from obesity and physical
inactivity.
