ATI MedSurg 3 Final Exam

A nurse assesses a client recovering from a cerebral angiography via the right femoral artery. Which assessment would the nurse complete? Palpate bilateral lower extremity pulses A client experiences impaired swallowing after a stroke and has worked with a speech-language pathologist on eating. What nurse assessment best indicates that the expected outcome for this problem has been met? Has clear lung sounds on auscultation A client with a severe traumatic brain injury has an organ donor card in his wallet. Which nursing action is appropriate? Contact the local organ procurement organization as soon as possible A client who is experiencing a traumatic brain injury has increasing intracranial pressure. What drug will the nurse anticipate to be prescribed for this client? Mannitol A client is admitted to the emergency department with a fractured femur resulting from a motor vehicle crash. What is the nurse's priority action? Assess airway, breathing, and circulation The nurse is caring for a client who has cirrhosis of the liver. What nursing action is appropriate to help control ascites? Provide a low-sodium diet The nurse is caring for a client who is prescribed lactulose. The client states,"I do not want to take this medication because it causes diarrhea." How would the nurse respond? Diarrhea is expected; that's how your body gets rid of ammonia A client is admitted with acute pancreatitis. What priority problem would the nurse expect they client to report? Severe boring abdominal pain After teaching a client who is prescribed pancreatic enzyme replacement therapy, the nurse assesses the clients understanding. Which statement by the client indicates a need for further teaching? "The best time to take the enzyme is immediately after i have a meal or snack." The nurse documents the vital signs of a` client diagnosed with acute pancreatitis: Apical pulse=116, RR=28, BP=92/50. What complication of acute pancreatitis would the nurse suspect that the client might have? Internal bleeding A nurse teaches a client with type 2 diabetes who is prescribed glipzide. Which statement would the nurse include in this clients teaching? Avoid taking NSAIDs After teaching a client who is DM with retinopathy, nephropathy, and peripheral neuropathy, the nurse assess the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? "I should look into swimming or water aerobics to get my exercise" The nurse assess a client with DKA. Which assessment finding would the nurse correlate with this condition? Increase rate and depth of respirations= Kussmal's Breathing A nurse teaches a client with DM about sick day management. Which statement would the nurse include in this clients teaching? "Monitor your blood glucose levels at least every 4 hours while sick" A nurse reviews the chart and new prescriptions for a client with DKA. Potassium is 2.6. What action would the nurse take? Increase the intravenous rate and then consult with the primary health care provider about the potassium prescription. A nurse cares for a client with a urine specific gravity of 1.040. What action would the nurse take? Increase the clients fluid intake The nurse assess a client who has possible bladder cancer. What common assessment finding associated with this type of cancer would the nurse expect? Painless hematuria The nurse is caring for four clients with chronic kidney disease. Which client would the nurse assess first upon initial rounding? Kussmal respirations The nurse is teaching a client with chronic kidney disease about sodium restrictions needed in the diet to prevent edema and hypertension. Which statement by the client indicates that more teaching is needed? "I am thrilled that i can continue to eat fast food" A client has been brought to the emergency department after being covered in fertilizer after an explosion and fire at a warehouse. What action by the nurse is best? Assess the client airway A client is in the oncology clinic for a first visit since being diagnosed with cancer. The nurse reads the clients chart that the cancer classification is Tis,N0, M0. What does that nurse conclude about the clients cancer? There are no distant metastasis noted in the report. A hospital responds to a local mass casualty event. What action would the nurse supervisor take to prevent staff post traumatic stress disorder during and after the event? Provide water and healthy snacks for energy throughout the event A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at a nurse when dinner is served late. How would the nurse respond? "You seem upset. I have time to talk if you'd like" A nurse cares for victims during a community disaster drill. One of the victims asks, "why are the individuals with black tags not receiving any care?" How does the nurse respond? "In a disaster, extensive resources are not used for one person at the expense of many others" A nurse is constructing a personal preparedness plan in case of a disaster. What does the nurse consider in making this plan? Store a basic supplies to last for at least 3 days The emergency department team is performing CPR on a client when the client's spouse arrives. Which action would the nurse take first? Ask the spouse if he or she wishes to be present during the resuscitation An emergency department nurse is triaging victims of a multi casualty event. Which client would receive care first? A 26 yo male who has pale, cool, clammy skin While triaging clients in a crowded ED, a nurse assesses a client who presents with symptoms of TB. What action would the nurse take first? Transfer the client to a negative-pressure room A nurse evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center? Level 2: located within community hospitals and provides care to most injured clients. A nurse is triaging clients in the ED. Which client would be considered "Urgent"? A 75 yo female with a cough and temp of 102 A nurse on the general medical-surgical unit is caring for a client in shock and assesses the following: Respiratory rate: 10 breaths/min Pulse: 136 beats/min Blood pressure: 92/78 mm Hg Level of consciousness: responds to voice Temperature: 101.5° F (38.5° C) Urine output for the last 2 hours: 40 mL/hr. What action by the nurse is best? a. Transfer the client to the Intensive Care Unit. b. Continue monitoring every 30 minutes. c. Notify the unit charge nurse immediately. d. Call the Rapid Response Team. d. Call the Rapid Response Team. . them at a higher risk for shock would the nurse assess? (Select all that apply.) a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutrition e. Overhydration f. Use of diuretics a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutrition f. Use of diuretics A nurse works at a community center for older adults. What self-management measure can the nurses teach the clients to prevent shock? a. Do not get dehydrated in warm weather b. Drink fluids on a regular schedule. c. Seek attention for any lacerations. d. Take medications as prescribed b. Drink fluids on a regular schedule. A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The client's arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L (18 mmol/L). Which sign or symptom does the nurse identify as an example of the client's compensatory mechanisms? a. Increased rate and depth of respirations b. Increased urinary output c. Increased thirst and hunger d. Increased release of acids from the kidneys (kidney's don't release acids they release bicarb) d. Increased release of acids from the kidneys (kidney's don't release acids they release bicarb) . A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement would the nurse include in this client's plan of care to delay the onset of microvascular and macrovascular complications? a. "Maintain tight glycemic control and prevent hyperglycemia." b. "Restrict your fluid intake to no more than 2 L a day." c. "Prevent hypoglycemia by eating a bedtime snack." a. "Maintain tight glycemic control and prevent hyperglycemia." After teaching a client who has diabetes mellitus with retinopathy, nephropathy, and peripheral neuropathy, the nurse assesses the client's understanding. Which statement made by the client indicate a correct understanding of the teaching? a. "I have so many complications; exercising is not recommended." b. "I will exercise more frequently because I have so many complications." c. "I used to run for exercise; I will start training for a marathon." d. "I should look into swimming or water aerobics to get my exercise." d. "I should look into swimming or water aerobics to get my exercise." A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt numbness in his left leg. Currently the client's neurologic examination is normal. What drug would the nurse plan to teach the patient? a. Alteplase b. Clopidogrel c. Heparin sodium d. Mannitol b. Clopidogrel-This client's signs and symptoms are consistent with a transient ischemic attack, and the client would likely be prescribed aspirin or clopidogrel to prevent platelet aggregation on discharge. Alteplase is used for ischemic stroke. Heparin and mannitol are not used for this condition. A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that the expected outcome for this problem has been met? a. Chooses preferred items from the menu. b. Eats 75 to 100% of all meals and snacks. c. Has clear lung sounds on auscultation. c. Has clear lung sounds on auscultation. A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. After raising the head of the bed, what action should the nurse take? Palpate the bladder for distention.- Indication of autonomic dysreflexia After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the his understanding. Which client statements indicate a correct understanding of the teaching related to sexual effects of his injury? (Select all that apply.) a. "I will explore other ways besides intercourse to please my partner." b. "I will not be able to have an erection because of my injury." c. "Ejaculation may not be as predictable as before." d. "I may urinate with ejaculation but this will not cause infection." e. "I should be able to have an erection with stimulation." c. "Ejaculation may not be as predictable as before." d. "I may urinate with ejaculation but this will not cause infection." e. "I should be able to have an erection with stimulation." Rationale: Men with injuries above T6 often are able to have erections by stimulating reflex activity. For example, stroking the penis will cause an erection. Ejaculation is less predictable and may be mixed with urine. However, urine is sterile, so the client's partner will not get an infection. A nurse plans care for a client with a halo fixator (traction for SCI) Which interventions would the nurse included in this client's plan of care? (Select all that apply.) a. Remove the vest for client bathing. b. Assess the pin sites for signs of infection. c. Loosen the pins when sleeping. d. Decrease the patient's oral fluid intake e. Assess the chest and back for skin breakdown a. Remove the vest for client bathing. b. Assess the pin sites for signs of infection. e. Assess the chest and back for skin breakdown Rationale: A special halo wrench should be taped to the client's vest in case of a cardiopulmonary emergency. The nurse should assess the pin sites for signs of infection or loose pins and for complications from the halo. The nurse should also increase fluids and fiber to decrease bowel straining and assess the client's chest and back for skin breakdown from the halo vest. A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.) a. Heart rate of 34 beats/min b. Blood pressure of 185/65 mm Hg c. Urine output less than 30 mL/hr d. Decreased level of consciousness e. Increased oxygen saturation a. Heart rate of 34 beats/min c. Urine output less than 30 mL/hr d. Decreased level of consciousness A nurse teaches a client who is recovering from a spinal fusion. Which statement should the nurse include in this client's postoperative instructions? a. "Only lift items that are 10 pounds or less." b. "Wear your brace whenever you are out of bed." c. "You must remain in bed for 3 weeks after surgery." d. "You are prescribed medications to prevent rejection." "Wear your brace whenever you are out of bed." An emergency department nurse cares for a client who experienced a spinal cord injury 1 hour ago. Which prescribed medication should the nurse prepare to administer? a. Intrathecal baclofen (Lioresal) b. Methylprednisolone (Medrol) c. Atropine sulfate d. Epinephrine (Adrenalin) b. Methylprednisolone (Medrol) Rationale: Methylprednisolone (Medrol) should be given within 8 hours of the injury. . A nurse teaches a client with a lower motor neuron lesion who wants to achieve bladder control. Which statement should the nurse include in this client's teaching? a. "Stroke the inner aspect of your thigh to initiate voiding." b. "Use a clean technique for intermittent catheterization." c. "Implement digital anal stimulation when your bladder is full." d. "Tighten your abdominal muscles to stimulate urine flow." d. "Tighten your abdominal muscles to stimulate urine flow." Rationale: In clients with lower motor neuron problems such as spinal cord injury, performing a Valsalva maneuver or tightening the abdominal muscles are interventions that can initiate voiding A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which assessment data should the nurse obtain to assess the client's coping strategies? (Select all that apply.) a. Spiritual beliefs b. Level of pain c. Family support d. Level of independence e. Annual income f. Previous coping strategies a. Spiritual beliefs c. Family support d. Level of independence f. Previous coping strategies A nurse cares for a client with a lower motor neuron injury who is experiencing a flaccid bowel elimination pattern. Which actions should the nurse take to assist in relieving this client's constipation? (Select all that apply.) a. Pour warm water over the perineum. b. Provide a diet high in fluids and fiber. c. Administer daily tap water enemas. d. Implement a consistent daily time for elimination. e. Massage the abdomen from left to right. f. Perform manual disimpaction. b. Provide a diet high in fluids and fiber. d. Implement a consistent daily time for elimination. f. Perform manual disimpaction. A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the client's hips and sacrum. Which actions should the nurse take? (Select all that apply.) a. Apply a barrier cream to protect the skin from excoriation. b. Perform range-of-motion (ROM) exercises for the hip joint. c. Re-position the client off of the reddened areas. d. Get the client out of bed and into a chair once a day. e. Obtain a low-air-loss mattress to minimize pressure. c. Re-position the client off of the reddened areas. e. Obtain a low-air-loss mattress to minimize pressure. A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.) a. Heart rate of 34 beats/min b. Blood pressure of 185/65 mm Hg c. Urine output less than 30 mL/hr d. Decreased level of consciousness e. Increased oxygen saturation a. Heart rate of 34 beats/min c. Urine output less than 30 mL/hr d. Decreased level of consciousness The nurse is preparing a client for discharge from the emergency department after experiencing a transient ischemic attack (TIA). Before discharge, which factor would the nurse identify as placing the client at high risk for a stroke? a. Age greater than or equal to 75 b. Blood pressure greater than or equal to 160/95 c. Unilateral weakness during a TIA d. TIA symptoms lasting less than a minute c. Unilateral weakness during a TIA Rationale: The client who has a TIA is at risk for a stroke is he or she has one-sided (unilateral) weakness during a TIA. Risk factors also include an age greater than or equal to 60, blood pressure greater than or equal to 140/90 (either or both systolic and diastolic), and/or a long duration of TIA symptoms. One minute is not a very long time for symptoms to occur. The nurse is taking a history from a daughter about her father's onset of stroke signs and symptoms. Which statement by the daughter indicates that the client likely had an embolic stroke? a. Client's symptoms occurred slowly over several hours. b. Client became increasingly lethargic and drowsy. c. Client reported severe headache before other symptoms. d. Client has a long history of atrial fibrillation. d. Client has a long history of atrial fibrillation. . A client is admitted with a sudden decline in level of consciousness. What is the nursing action at this time? a. Assess the client for hypoglycemia and hypoxia. b. Place the client on his or her side. c. Prepare for administration of a fibrinolytic agent. d. Start a continuous IV heparin sodium infusion. a. Assess the client for hypoglycemia and hypoxia. A nurse is triaging clients in the emergency department. Which client would the nurse classify as "nonurgent?" a. A 44 year old with chest pain and diaphoresis b. A 50 year old with chest trauma and absent breath sounds c. A 62 year old with a simple fracture of the left arm C d. A 79 year old with a temperature of 104° F (40.0° C) c. A 62 year old with a simple fracture of the left arm What is the primary goal of a triage system used by the nurse with clients presenting to the emergency department? a. Determine the acuity of the client's condition to determine priority of care. b. Assess the status of the airway, breathing, circulation, or presence of deficits. c. Determine whether the client is responsive enough to provide needed information. d. Evaluate the emergency department's resources to adequately treat the patient. a. Determine the acuity of the client's condition to determine priority of care. A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag? a. Dislocated right hip and an open fracture of the right lower leg b. Large contusion to the forehead and a bloody nose c. Closed fracture of the right clavicle and arm numbness d. Multiple fractured ribs and shortness of breath d. Multiple fractured ribs and shortness of breath . A nurse is constructing a personal preparedness plan in case of a disaster. What does the nurse consider in making this plan? a. Store basic supplies to last for at least 3 days. b. Have short-term arrangements for child care. c. Store enough frozen foods in the freezer for 5 days. d. Keep cooking utensils needed in a separate bag. a. Store basic supplies to last for at least 3 days. A hospital prepares to receive large numbers of casualties from a community disaster. Which clients would the nurse identify as appropriate for discharge or transfer to another facility? (Select all that apply.) a. Older adult in the medical decision unit for evaluation of chest pain b. Client who had open reduction and internal fixation of a femur fracture 3 days ago c. Client admitted last night with community-acquired pneumonia d. Infant who has a fever of unknown origin e. Client on the medical unit for wound care f. Client with symptoms of influenza after traveling abroad b. Client who had open reduction and internal fixation of a femur fracture 3 days ago e. Client on the medical unit for wound care The nurse caring for clients admitted for infectious diseases understands what information about emerging global diseases and bioterrorism? a. Many infections are or could be spread by international travel. b. Safer food preparation practices have decreased foodborne illnesses. c. The majority of Americans have adequate innate immunity to smallpox. d. Plague produces a mild illness and generally has a low mortality rate. a. Many infections are or could be spread by international travel. The nurse is teaching assistive personnel (AP) about care for a male client diagnosed with acute ischemic stroke and left-sided weakness. Which statement by the AP indicates understanding of the nurse's teaching? a. "I will use "yes" and "no" questions when communicating with the client." b. "I will remind the client frequently to not get out of bed without help." c. "I will offer a urinal every hour to the client due to incontinence." d. "I will feed the client slowly using soft or pureed foods." b. "I will remind the client frequently to not get out of bed without help." Rationale: The client who has left-sided weakness has likely had a right-sided stroke in the brain. Clients who have strokes on the right side of the brain tend to be very impulsive and exhibit poor judgment. Therefore, to keep the client safe, the staff will need to remind the client to stay in bed unless he has assistance to prevent falling. A nurse receives a hand-off report on a female client who had a left-sided stroke with homonymous hemianopsia (blindness on the same side of both eyes). What action by the nurse is most appropriate for this client? a. Assess for bladder and bowel retention and/or incontinence. b. Listen to the client's lungs after eating or drinking for diminished breath sounds. c. Support the client's left side when sitting in a chair or in bed. d. Remind the client to move her head from side to side to increase her visual field. d. Remind the client to move her head from side to side to increase her visual field. A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain? a. Loss of bladder control b. Other medical conditions c. Progression of symptoms d. Time of symptom onset (the time limit for intiating fibrinolytic therapy for a stroke is 3 to 4.5 hours d. Time of symptom onset (the time limit for intiating fibrinolytic therapy for a stroke is 3 to 4.5 hours The nurse is preparing to administer IV alteplase for a client diagnosed with an acute ischemic stroke. Which statement is correct about the administration of this drug? a. The recommended time for drug administration is within 90 minutes after admission to the emergency department. b. The drug is given in a bolus over the first 3 minutes followed by a continuous infusion. c. The maximum dosage of the drug, including the bolus, is 120 mg intravenously. d. The drug is not given to clients who are already on anticoagulant or antiplatelet therapy. d. The drug is not given to clients who are already on anticoagulant or antiplatelet therapy. A client is receiving IV alteplase and reports a sudden severe headache. What is the nurse's first action? a. Perform a comprehensive pain assessment. b. Discontinue the infusion of the drug. (severe headache means increased BP) c. Conduct a neurologic assessment. d. Administer an antihypertensive drug. b. Discontinue the infusion of the drug. (severe headache means increased BP) A male client was admitted with a left-sided stroke this morning. The assistive personnel asks about meeting the client's nutritional needs. Which response by the nurse is appropriate? a. "He is NPO until the speech-language pathologist performs a swallowing evaluation." b. "You may give him a full-liquid diet, but please avoid solid foods until he gets stronger." c. "Just be sure to add some thickener in his liquids to prevent choking and aspiration." d. "Be sure to sit him up when you are feeding him to make him feel more natural." a. "He is NPO until the speech-language pathologist performs a swallowing evaluation." . A nurse is providing community screening for risk factors associated with stroke. Which person would the nurse identify as being at the highest risk for a stroke? a. A 27-year-old heavy-cocaine user. b. A 30-year-old who drinks a beer a day. c. A 40-year-old who uses seasonal antihistamines. d. A 65-year-old who is active and on no medications. a. A 27-year-old heavy-cocaine user. The nurse is caring for four clients with traumatic brain injuries. Which client would the nurse assess first? a. Client with amnesia for the incident b. Client who has a Glasgow Coma Scale score of 12 c. Client with a PaCO2 of 36 mm Hg and on a ventilator d. Client who has a temperature of 102° F (38.9° C) d. Client who has a temperature of 102° F (38.9° C) After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes, acute confusion, and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse would the nurse take first? a. Assess the client's urinary output. b. Assess the client's serum sodium level. c. Increase the rate of the IV infusion. d. Provide oral care every hour. b. Assess the client's serum sodium level. Rationale: This client has signs and symptoms of hypernatremia, which is a possible complication after craniotomy. The nurse would assess the client's serum sodium level first and then possibly increase the rate of the IV infusion.