ATI RN MEDICAL SURGICAL PROCTORED EXAMS 25 LATEST MULTIPLE VERSIONS EXAMS GRADE A+

Medical Surgical ATI Lyme Disease A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Understanding of the patient teaching. ANS: My joints ache because I have Lyme disease. Chronic complications memory problem and fatigue Musculoskeletal: Osteoporosis/Osteomyelitis A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of the following findings is a manifestation of this condition? ANS: Pain that increases with passive movement. Other s/s diminished pulse or pulselessness and capillary refill greater than 2 seconds in the affected extremity. Warmth indicates infection. A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the following instructions should the nurse include? Flex the foot every hour when awake. Avoid placing pillows under the knee. Elevate the leg when sitting in a chair to reduce edema and pain. Keep the operative leg in a neutral position when resting in bed Teaching external fixation device for fracture of lower extremity: use crutches with rubber tip. Casts/splints/boots applied. Continuous use for 4-6 weeks. Teach wound and pin care. Only provider can adjust. Post-op open reduction internal fixation of the ankle. What assessment report: extremity cool on palpation. Other findings to report: pallor, cool temp, paresthesia A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following nonpharmacological interventions should the nurse suggest to the client to reduce pain? Alternate application of heat and cold to the affected joints. Diet high in nutrients, such as protein, vitamins, and iron, to promote tissue repair. Elevation of the affected extremities does not relieve the painful inflammation caused by rheumatoid arthritis. Downloaded by: NURSEDENIM | Distribution of this document is illegal Elevation of the extremities can assist with managing the pain of a client who has peripheral vascular disease. Regular exercise is important to prevent stiffness. Caring for a client with hx of a compound fracture, 3 wks ago. Unexpected finding showing osteomyelitis? ANS: Sedimentation rate. An increased sedimentation rate occurs when a client has any type of inflammatory process, such as osteomyelitis. A nurse is teaching a client about osteoporosis prevention. The nurse should instruct the client which of the following medications can increase their risk of developing osteoporosis? ANS: Prednisone. The nurse should instruct the client that prednisone can increase the risk for developing osteoporosis due to suppression of bone formation, and an increase in bone resorption by osteoclasts. Prednisone can also reduce intestinal absorption of calcium. Conjugated estrogen reduces risk. Colchicine can cause aplastic anemia. A nurse is providing education to a client who is at risk for osteoporosis. Which of the following instructions should the nurse include? Walk for 30 mins four times per week. Other teaching: Glucosamine for pain, avoid exercises that cause jarring motions, such as jogging, take over-the-counter calcium supplements. Procedures Suctioning client tracheostomy tube. Signs of hypoxia: The client’s heart rate increases. Coughing is expected. Late signs are diaphoresis and a decrease in blood pressure and will not be seen now. An increase in blood pressure is an early sign. A nurse is caring for a client who has an arterial line. Nursing action to take? ANS: Place a pressure bag around the flush solution. Arterial line used for ABG samples and hemodynamic monitoring. Supine, HOB 60 degrees. Downloaded by: NURSEDENIM | Distribution of this document is illegal A nurse is assessing a client following the completion of hemodialysis. Which of the following findings is the nurse's priority to report to the provider? Restlessness. Expected: inc temp, dec BP, weight loss. A nurse is providing teaching to a client who has end-stage kidney disease and is waiting for a kidney transplant. Which of the following information should the nurse provide? Hemodialysis is sometimes required following surgery. Transplant can come from a living or deceased donor. Lifelong immunosuppressive therapy is necessary for the organ recipient. Following transplant, clients should follow dietary restrictions to prevent rejection. A nurse is caring for a client who had a nephrostomy tube inserted 12hrs ago. Report to the doc? ANS: The client complains of back pain. This indicates the tube may have clogged or is dislodged. Report decrease in UO. Red tinged urine expected post 12-24hrs Planning care for a client who is scheduled for a thoracentesis. Nursing interventions. ANS: Encourage the client to take deep breaths after the procedure. Other: upright position, arm resting overhead table, local anesthetic, npo not needed. Resumes activity within 1 hr post procedure. A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The client's inital vital signs were HR 80, BP 130/70, R 16, and temp 96.8. Which of the following vital sign changes should alert the nurse that the client might be hemorrhaging? HR 110. one of the first signs of hemorrhage is an increase in the heart rate from the client's baseline, which occurs to compensate for blood loss. An early sign of hemorrhage is a slight increase in the diastolic blood pressure. As bleeding progresses, the systolic blood pressure will decrease. An increase in blood pressure postoperatively can indicate that the client is in pain. An increase in the respiratory rate from the client’s baseline is an indication of hemorrhage. An increase in temperature from the client’s baseline is an indication of infection, not hemorrhage. Downloaded by: NURSEDENIM | Distribution of this document is illegal A nurse is caring for a client following extubation of an endotracheal tube 10 mins ago. Priority to report? ANS: Stridor. Expected findings: hoarseness, sore throat, oral secretions TURP post opp, clots in indwelling catheter: irrigate the catheter. Traction applied to reduce risk of bleeding. A nurse is planning for a client who is postoperative following a laparotomy and has a closed-suction drain. Which of the following actions should the nurse take to manage the drain? ANS: Compress the drain reservoir after emptying Compressing the reservoir creates a vacuum that draws fluid out of the wound, through the drain, and into the reservoir. A closed-suction drain uses a reservoir for collecting drainage and applies negative pressure, which allows the drainage to collect in the reservoir rather than relying on gravity, and does not require wall suction. A Penrose drain allows drainage to collect on a sterile gauze dressing. A nurse is teaching a client about the use of transcutaneous electrical nerve stimulation (TENS) for the management of bone cancer pain. The nurse should explain that applying a TENS unit to the painful area has which of the following effects? A tingling sensation replacing the pain. A TENS unit applies small electric currents to the painful area, with the client increasing the current until the “pins and needles” sensation overrides the pain. Elimination 8 hr post opp total hip arthroplasty. Unable to void in a bedpan. Action take first: Scan the bladder with a portable ultrasound. TB Discharge teaching active TB (Tuberculosis): Sputum specimens q 2-4 w until there are three negative cultures. Client no longer contagious post 2-3 weeks of initiation of TB medications. Family members take no precautions because Downloaded by: NURSEDENIM | Distribution of this document is illegal they have already been exposed. Follow up evaluation chest X-Ray, not skin test. TB patient and family education: Family members in the household should undergo TB testing. Other teaching: cover mouth when cough/sneeze and suppose tissues in plastic bag. Wear mask in public. TB precautions: Airborne. Other diseases that need airborne: measles, varicella, disseminated varicella zoster. Droplet: flu, rubella, pneumonia, streptococcal pharyngitis, pertussis, mumps. Contact: MRSA, VRE, respiratory syncytial virus, scabies, c-diff. Protective: immunocompromised. Medications Inc ICP. Receive Mannitol. Adverse Effect: Other adverse effects: tachycardia, edema, dyspnea, decreased O2 sat. Therapeutic effect: increased urinary output. Teaching for psyllium (bulk forming laxative). 240 ml or 8 oz of water drink post administration. Works in 12-24 hrs, expect BM regularity in 2-3 days. Take it post meals. Increase dietary fiber to help constipation. Warfarin for Afib, desired outcome: INR 2.5 (2-3 target range). Heparin aPTT 45-90 A nurse is obtaining a medication history from a client who is scheduled to undergo cataract surgery. The nurse should recognize that which of the following client medications is a contradiction for the surgery and notify the provider? Warfarin. Warfarin increases the client's risk for bleeding, and is contraindicated for a client scheduled for eye or central nervous system surgery. Osteomyelitis gentamicin prescription withhold: serum creatinine (nephrotoxic). High temp, BP, and WBC expected. Downloaded by: NURSEDENIM | Distribution of this document is illegal A nurse is providing discharge teaching to a client who is to self administer heparin subcut. Understanding of the teaching? ANS: I will use an electric razor to shave. Heparin is an anticoagulant that places the client at the risk for bleeding. Therefore, the nurse should instruct the client to use an electric razor when shaving to reduce the risk of cuts to the skin, avoid flossing, apply firm pressure to the injection site for 1 to 2 min but to avoid massaging it. A nurse is providing teaching to a client who is premenopausal and is on hormone replacement therapy. Adverse effects. ANS: Calf pain, numbness in arms, intense headache. Night sweats and vaginal dryness are expected findings of menopause. A nurse is reviewing the laboratory results of a client who has AIDS and is taking amphotericin B for a fungal infection. The nurse should identify that which of the following values is an indication of an adverse effect of the medication? BUN 34 mg/dL. Amphotericin B can cause damage to the kidneys and can cause several metabolic imbalances, including hyponatremia, hypokalemia, and hypomagnesemia. It can also cause bone marrow suppression and, as a result, a decreased hematocrit. Amphotericin B is nephrotoxic. Therefore, an elevated BUN or creatinine level can indicate renal impairment. The nurse should notify the provider of this result. A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following information should the nurse include in the teaching? "Increase fiber intake to avoid constipation" Verapamil with meals or milk to decrease gastric irritability. Eczema can develop 3 to 6 months after the beginning of verapamil therapy. constipation is an adverse effect of verapamil. Monitor blood pressure weekly and report manifestations of hypotension to the provider. Mastectomy Post opp modified radical mastectomy: numbness can occur along the inside of the affected arm. Other teaching: stand upright and avoid flexing Downloaded by: NURSEDENIM | Distribution of this document is illegal the affected arm when ambulating. Active ROM 1 week post opp. Wear loose fitting clothing. A nurse is providing pre-op teaching for a client who is scheduled for a mastectomy. Statements the nurse should make? ANS: I will refer you to community resources for support A nurse is planning care for a client who is having a modified radical mastectomy of the right breast. Which of the following interventions should the nurse include in the plan of care? Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24 hr period. Remains in place - 1-3 weeks post surgery. Exercise 24 h post. Elevate affected arm on pillow. HOB 30 degree. Infection A nurse is caring for a client who has a positive culture for methicillin- resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take? Bathe the client using chlorhexidine solution. Nasal specimen for colonization. Visitors gown and gloves. Dosage Order: 600mg Available: 125 mg/5ml ANS: 24ml Cancer A patient receiving chemotherapy. The priority is: Sore throat. Expected: memory loss. Alopecia: cover head. A nurse is caring for a client who has terminal cancer. The client tells the nurse, "I wish I could stop these treatments. I am ready to die." Which of the following statements should the nurse make? "Discontinuing the treatments is your choice if it is your wish to do so." the nurse should recognize the client's right to refuse the treatments and inform the client of this right Downloaded by: NURSEDENIM | Distribution of this document is illegal A nurse is providing teaching to a client who has stage II cervical cancer and is scheduled for brachytherapy. Which instruction should the nurse include? ANS: You will need to stay in bed during each treatment session. Excessive movement can cause the radioactive source to become dislodged. There will likely be between two and five treatments, once or twice each week. there is not excreted radiation between treatments. Therefore, there are no restrictions regarding contact with others. Urine is an adverse effect of brachytherapy and is not an expected finding. Therefore, the client should report this finding to the provider immediately. A nurse is providing discharge teaching to a client who has laryngeal cancer and is receiving radiation therapy. Understanding of the teaching? ANS: I will avoid direct sun exposure. The client should avoid exposure of irradiated skin areas to the sun for at least 1 year after completing radiation therapy. Skin in the radiation path is especially sensitive to sun damage. Head and neck radiation can damage the salivary glands and cause dry mouth, which predisposes the client to mucositis. The client should rinse the mouth with plain water or 0.9% sodium chloride.Health care providers who care for clients receiving radiation therapy should wear a dosimeter badge to measure radiation exposure. The client does not need to wear a badge. The client should not remove the markings until the course of radiation is complete because radiation markings ensure consistent dose delivery to the target area. A nurse is planning care for a client who has a sealed radiation implant for cervical cancer. Which of the following interventions should the nurse include in the plan of care? Keep a lead-lined container in the client's room (and forceps). Restrict visitors to 30 mins per day. Nurse and staff dosimeter. Soiled linens in room until implant removed. Advanced lung cancer, undergoing thoracentesis. Which manifestation of lung cancer will be reduced: dyspnea. Other therapies: Radiation will decrease pain, dysphagia, and hemoptysis. Mucolytics will help in reducing mucus production. Systemic Lupus Erythematosus Systemic Lupus Erythematosus expected findings- Facial butterfly rash. Other s/s Abdominal pain. tachycardia as a manifestation of pericarditis, which is a complication of SLE. Systemic sclerosis manifestations esophagitis, interstitial fibrosis. Diabetes/DKA A nurse is assessing a client who has diabetes insipidus. Expected findings. ANS: Low urine specific gravity. Other expected: hypotension, weak peripheral pulses, polydipsia, polyuria. Caring for a client who has DKA. What shows client’s condition is improving? ANS: Glucose 272 mg/dL. A glucose reading less than 300 mg/dL indicates improvement in the client's status. The potassium level of a client who has DKA might be below, at, or above the expected reference range. Low Ph expected finding and An HCO3- level of 14 mEq/L is an expected finding of DKA therefore don’t indicate improvement. Caring for a client who has DKA. Plan to administer what? ANS: Regular insulin 20 units IV bolus. Results in dehydration, ketosis, metabolic acidosis, and elevated blood glucose levels. AIDS AIDS infection prevention teaching: avoid flossing teeth. Other teaching: avoid eating salads, raw fruits and vegetables. Disposable gloves under gardening gloves when working with soil, garden, house plants. Avoid drinking fluids that have been out for longer than 1hr. A nurse is providing teaching to a client who has AIDS. Which of the following statements by the client indicated an understanding of the teaching? "I will take my temperature once a day" clean tooth brush weekly in dishwasher or bleach. Temp more than 100 is a problem. Anemia Pernicious anemia tongue picture: The tongue which is smooth and glassy looking Anemia oral iron supplement: “I will eat more high fiber foods”, no dairy and antacids with iron, increase red meat. Culture and Diversity Health promotion African American disorder greatest risk: Hypertension. Caucasian Urolithiasis. Skin cancer - light skinned. Aplastic Anemia: WBC 2000 Blood Transfusion A nurse is preparing to administer a blood transfusion to a client who has anemia. Action to take first? ANS: Check for the type and number of units blood to administer. A nurse is administering packed RBCs to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction? Low back pain and apprehension. Graft versus host disease s/s: thrombocytopenia, anorexia, nausea, chronic hepatitis, and weight loss. Allergic reaction s/s: bronchospasm, urticaria, anaphylaxis. Infusion too fast: HTN, restlessness, bounding pulse. A nurse is caring for a client who is receiving blood transfusion. The client becomes restless, dyspneic, and has crackles in the lungs. Nursing action. ANS: Slower the infusion rate. These are manifestations of circulatory overload. Manifestations of an allergic reaction to a blood product include hives and itching. Corticosteroids are prescribed to manage a septic or allergic transfusion reaction. The nurse should elevate the head of the client's bed and lower the client's legs to manage the client's manifestations. The nurse should apply oxygen and anticipate a prescription for a diuretic or morphine. Respiratory Substernal precordial pain sound recording: pericardial friction rub Long-term mechanical ventilation complication: stress ulcers. Other complications: decreased cardiac output, hypotension, fluid retention, hyponatremia. Stress ulcers in clients who are receiving long-term mechanical ventilation are caused by elevated levels of hydrochloric acid in the stomach. Stress ulcers increase the risk for systemic infection and require pharmacological treatment. A nurse is providing teaching to client who has asthma about the use of metered-dose inhaler. Understanding of the teaching? ANS: Holding breath for 10 seconds after inhalation. The client should wait at least 1 min between puffs on the inhaler. The client should either rinse the plastic case and cap of the inhaler with warm running tap water once daily or soak it in 480 mL (16 oz) of water with 60 mL (2 oz) of vinegar once per week. Breathe slow and deep. A nurse is caring for a client who has a pneumothorax and a closed chest drainage system. Finding that indicates lung re-expansion? ANS: Bubbling in the water seal chamber has ceased. Bubbling in the water seal chamber ceases when the lung re-expands. Serosanginous fluid is expected. Tidaling is up and down movement expected with breathing. A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the following results should the nurse expect? ANS: PaCO2 56 mm Hg A client who has COPD retains PaCO2 due to the weakening and the collapse of the alveolar sacs, which decreases the area in the lungs for gas exchange and causes the PaCO2 to increase above the expected reference range. A client who has COPD will have a pH less than 7.35 due to poor gas exchange resulting from having elevated PaCO2 and HCO3- levels, along with low oxygen levels, for an extended period of time. A client who has COPD will have high HCO3- levels as a result of the kidneys' inability to excrete metabolic acids, leading to a retention of HCO3- in the blood and an increase in pH. A client who has COPD will have a low oxygen level due to the weakening and collapse of the alveolar sacs, which decreases the area available in the lungs for gas exchange. Cardiovascular Prevention of atherosclerosis: smoking cessation, maintain appropriate weight, eat low fat diet. Other: increase intake of fruits, veggies and grains. Decrease intake of simple sugars. A nurse is reviewing the lab findings of a client who developed chest pain 6 hrs ago. Identify as an indication of Myocardial Infarction (MI)? ANS: Troponin 18 ng/mL A nurse is teaching a client who has a cardiac dysrhythmia about the purpose of undergoing continuous telemetry monitoring. Which of the following statements by the client reflects an understanding of the teaching? "This identifies if the pacemaker cells of my heart are working properly" Telemetry detects the ability of cardiac cells to generate a spontaneous and repetitive electrical impulse through the heart muscle. An echocardiogram, a noninvasive ultrasound procedure, evaluates heart valve function and structure. Cardiac catheterization allows for the measurement of coronary artery blood flow. Peripheral Arterial disease expected: hair loss on lower legs. Other expected: painful ulcerations of end of toes, pain when resting, relieved by dangling, dependent rubor. A nurse is checking the ECG rhythm strip for a client who has a temporary pacemaker. The nurse notes a pacemaker artifact followed by a QRS complex. Which of the following actions should the nurse take? Document that depolarization has occurred. Sensitivity should be decreased if the pacemaker fires at a regular rate in the presence of an adequate intrinsic rhythm, which is not the case for this client. Skin Teaching stage one pressure injury greater trochanter: change position q 1 hour. Other teaching: clean and dry, moisturize with cream or lotion. Don’t use donut shaped pillows. Limit angle of hips when in lateral position to 30 degrees. No massage Alternative Therapies Ginkgo Baloba teaching: increase risk of bleeding. Other herbs: ginger root treats nausea caused by vertigo, glucosamine treats joint pain, feverfew decreases migraine HAs A nurse is caring for a client who has breast cancer and would like acupuncture. Nurse’s statement should be? ANS: I can speak to the provider about incorporating acupuncture into your treatment plan. Nurse’s role as a pt advocate. Other acupuncture uses: pain control, fatigue, hot flashes, N/V in breast cancer patients Thyroid