ATI Med-Surg Proctored Exam Review verified 100% CORRECT!!!

ATI Med-Surg Proctored Exam Review verified 100% CORRECT!!! Respiratory Alkalosis S/S - ANS-lethargy lightheadedness confusion tachycardia dysrhythmias related to hypokalemia nausea vomiting epigastric pain numbness and tingling of the extremities hyperventilation (tachypnea) A nurse is contributing to the plan of care for an older adult client who is at risk for Osteoporosis. Which intervention should the nurse include to prevent bone loss? - ANS-Encourage weight bearing exercises (such as walking because it can help maintain bone mass by reducing bone demineralization, thus helping to prevent osteoporosis.) A nurse is caring for a client who has meningococal pneumonia. Which of the following personal protective equipment should the nurse use? - ANS-Mask (this disease requires droplet precautions) A nurse is reinforcing teaching with a client who is taking insulin Glargine. What information should the nurse include in the teaching? - ANS-This type of insulin should be given at the same time everyday. (It is released over a 24hr period) A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. What statement by the client indicates that they are adhering to the nurse's instructions? - ANS-"I don't cross my legs anymore". A nurse is caring for a client who has a methicillin-resistant Staphlococcus aureus (MRSA) infections in a surgical wound. What information should the nurse plan to share with visitors? - ANS-Visitors must don a gown & gloves prior to entering the client's room. A nurse is reinforcing teaching with a client who has heart failure and a new prescription for hydrochlorothiazide. What should the client report to the provider? - ANS-Onset of nausea A nurse is reinforcing discharge teaching with a client who has hearing loss. What action should the nurse take when communicating with the client? - ANS-Rephrase client instructions when not understood. A nurse is caring for a client who is 1 day post operative following a hip arthroplasty. The client is exhibiting hypotension, tachycardia, & tacky-nearly. The nurse should recognize these findings as what complication? - ANS-Pulmonary Embolism A nurse is monitoring a client who recently had a cast placed on the right lower extremity for a bone fracture. What finding should the nurse recognize as abnormal? - ANS-Lack of sensation between the first and second toes A nurse reinforcing teaching with a client who has systemic lupus erythematosus (SLE) and is to begin taking methylprednisolone orally. What should the nurse include in the teaching? - ANS-Limit contact with large groups of people A nurse is caring for a client who is 24hr postoperative following abdominal surgery & has an NG tube. What action should the nurse plan to take to decrease the risk of postoperative complications? - ANS-Encourage the client to use an incentive spirometer every hour while awake A nurse is collecting data from a client who has chronic kidney disease with hyperkalemia. What finding should the nurse expect related to hyperkalemia? - ANS-Bradycardia A nurse is assisting in the care of a client who has manifestations of sepsis. What provider prescriptions should the nurse implement first? - ANS-Initiate oxygen at 4 L/min via nasal cannula A nurse is caring for a client who has terminal pancreatic cancer. The client states, "I don't think I can go on any longer." What response should the nurse make? - ANS-"Tell me more about the way you are feeling." A nurse is collecting data from a client who has hypokalemia. What finding should the nurse identify as the priority? - ANS-Dysrhythmia A nurse is caring for a client who is in Buck's traction. What intervention should the nurse perform to reduce skin breakdown? - ANS-Keep the skin dry and free of perspiration A nurse is contributing to the plan of care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infections and is on contract isolation precautions. What action should the nurse take? - ANS-Have a designated stethoscope in the client's room A nurse enters the room of a client whose transfusion of packed RBCs was initiated 15 min ago by the RN. The client reports dyspnea and urticaria. What action should the nurse perform first? - ANS-Stop the infusion A nurse is preparing to auscultate the bowel sounds of a client who has a mechanical bowel obstruction in the descending colon. When listening in the left upper quadrant, the nurse should identify this sound as what? - ANS-Hyperactive bowel sounds A nurse is preparing to administer furosemide to a client who has heart failure. What should the nurse report before administering the medication? - ANS-Decreased potassium A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis. What information should the nurse include in the teaching? - ANS-Apply cold packs to the joints A nurse is collecting data from a client who has hypothyroidism. What manifestation should the nurse expect? - ANS-Bradycardia A nurse is reinforcing teaching with an older adult client who has osteoporosis. What instructions should the nurse include in the teaching? - ANS-Take the calcium supplements with meals