med surg ati proctored exam (Sent) Questions and Answers with complete solutions

med surg ati proctored exam (Sent) Questions and Answers with complete solutions 43. A nurse is preparing to discharge a client who has halo device and is reviewing new prescriptions from the provider. The nurse should clarify which of the following prescriptions with the provider? a. Increase intake of fiber-rich foods b. May place a small pillow under head when sleeping c. May operate a motor vehicle when no longer taking analgesics d. Take a tub bath instead of showers - ANS -c. May operate a motor vehicle when no longer taking analgesics A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take? a. Familiarize themselves with commonly used sign language b. Ask a family member to be present during the admission c. Obtain a board that uses colored pictures as communication d. Request an interpreter during the initial assessment - ANS -d. Request an interpreter during the initial assessment A critical care nurse is assessing a client who has severe head injury. In response to painful stimuli, the client does not open her eyes, displays decerebrate posturing, and makes incomprehensible sounds. Which of the following Glasgow Coma Scale scores should the nurse assign the client? a. 5 b. 2 c. 13 d. 10 - ANS -a. 5 A home care nurse is planning to use nonpharmacological pain relief measures for an older adult client who has severe chronic back pain. Which of the following guidelines should the nurse use? a. Discontinue opioids before trying nonpharmacological methods of pain relief b. Use imagery with clients who have difficulty with focus and concentration c. Distraction changes the client's perception of pain, but does not affect the cause d. Pain relief from the use of heat and cold continues for several hours after removal of the stimulus - ANS -c. Distraction changes the client's perception of pain, but does not affect the cause A home health nurse is making an initial visit to a client who has multiple sclerosis. Which of the following actions is the priority for the nurse to take? a. Discuss recommendations for eating and swallowing techniques b. List strategies for family coping when dealing with possible role changes c. Review the use of adaptive grooming devices to promote client independence d. Give the client information about the local national multiple sclerosis society - ANS -a. Discuss recommendations for eating and swallowing techniques A nurse in a clinic is providing preventive teaching to an older adult client during a well visit. The nurse should instruct the client that which of the following immunizations are recommended for healthy adults after the age of 60? Select All That Apply a. Herpes zoster b. Influenza c. Meningococcal d. Human papillomavirus e. Pneumococcal polysaccharide - ANS -a. Herpes zoster b. Influenza e. Pneumococcal polysaccharide A nurse in a clinic receives a phone call from a client who recently started therapy with an ACE inhibitor and reports a nagging dry cough. Which of the following responses by the nurse is appropriate? a. "your cough may require that you stop or change your medication" b. "Increasing your daily fluid intake may eliminate your cough" c. "sucking on lozenge may reduce the frequency of your cough" d. You cough should go away in time" - ANS -a. "your cough may require that you stop or change your medication" A nurse in a provider's office is teaching a client about the self-management of GERD. Which of the following instructions should the nurse include? a. "eat a light meal 1 hour before bedtime" b. "sleep with head of your bed elevated 6 inches" c. "increase your caloric intake by 250 calories per day" d. "lie down for 30 min after each meal" - ANS -b. "sleep with head of your bed elevated 6 inches" A nurse in an emergency department is preparing to perform an ocular irrigation for a client. Which of the following actions should the nurse plan to take? a. Assess the client's visual acuity prior to irrigation b. Have the client turn their head toward the unaffected eye c. Hold the irrigator syringe 3.81 cm (1.5 in) above the eye d. Perform the irrigation with sterile water for irrigation - ANS -d. Perform the irrigation with sterile water for irrigation A nurse in the emergency department is assessing a client. Which of the following actions should the nurse take first? Exhibit a. Obtain a sputum sample for culture b. Administer ondansetron c. Initiate airborne precautions d. Prepare the client for a chest x-ray - ANS -c. Initiate airborne precautions A nurse in the emergency department is caring for a client who has a gunshot wound to the abdomen. Which of the following actions should the nurse take first? a. Check the color of the client's skin b. Remove all of the client's clothing c. Administer an opioid analgesic d. Prepare the client for periorbital lavage - ANS -a. Check the color of the client's skin A nurse in the emergency department is caring for a client who is in hypovolemic shock. Which of the following actions should the nurse take first? a. Obtain a blood specimen for type and crossmatch b. Insert a large-bore IV catheter c. Administer IV therapy d. Monitor urine output - ANS -b. Insert a large-bore IV catheter A nurse in the PACU is assessing a client who is postoperative following general anesthesia. Which of the following findings is the priority to address? a. Vomiting upon arousal b. Decreased body temperature c. Indistinct, rambling speech d. Piloerection of the skin - ANS -a. Vomiting upon arousal A nurse in the post-anesthesia care unit is assessing a client following an appendectomy and finds a 2-cm (3/4in) area of blood on the postoperative dressing. Which of the following actions should the nurse take? a. Apply pressure b. Loosen the dressing c. Circle the drainage d. Apply a new dressing - ANS -c. Circle the drainage A nurse is a planning care for a client who has full-thickness burns on the lower extremities. Which of the following interventions should the nurse include? a. Apply new gloves when alternating between wound care sites b. Provide a diet of fresh fruits and vegetables for the client c. Limit visitation time for the client's children to 40 min per day d. Clean the equipment in the client's room once per week - ANS -a. Apply new gloves when alternating between wound care sites A nurse is admitting a client to a medical unit following placement of a permanent pacemaker. Which of the following findings requires further assessment by the nurse? a. Sneezing b. Hiccups c. Presence of a sharp spike prior to the QRS complex on the ECG d. Presence of intrinsic P waves following a QRS complex on the ECG - ANS -b. Hiccups A nurse is admitting a client to the emergency department after a gunshot wound to the abdomen. Which of the following actions should the nurse take to help prevent the onset of acute kidney failure? a. Initiate beta blocker therapy b. Insert a urinary catheter c. Prepare the client for an intravenous pyelogram d. Administer IV fluids to the client - ANS -d. Administer IV fluids to the client A nurse is assessing a client following extubation from a ventilator. For which of the following findings should the nurse intervene immediately? a. Rhonchi b. SaO2 92% c. Sore throat d. Stridor - ANS -d. Stridor A nurse is assessing a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following findings indicates that the client is experiencing hypoglycemia? a. Abdominal cramping b. Increased perspiration c. Dehydration d. Fruity odor to breath - ANS -b. Increased perspiration A nurse is assessing a client who has arteriovenous (AV) graft in the left forearm. Which of the following findings should indicate to the nurse a complication of vascular access? a. 2+ left radical pulse b. Absence of a bruit c. Presence of a palpable thrill d. Dilated appearance of the AV site - ANS -b. Absence of a bruit A nurse is assessing a client who has heart failure and is receiving a loop diuretic. Which of the following findings indicates hypokalemia? a. Oliguria b. Hypertension c. Muscle weakness d. Positive chvostek's sign (CHEEK) - ANS -c. Muscle weakness A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? a. Flushed skin b. Frothy sputum/Hacking cough