ATI Med Surg Proctored Exam 4 verified
100 %
Ankolderkadultkiskbroughtktokankemergencykdepartmentkbykakfamilykmember.kWhichkofkth
ekfollowingkassessmentkfindingskshouldkcausektheknursektoksuspectkthatkthekclientkhask
hypertonickdehydration?k-kUrinekSpecifickgravityk1.045
Akurinekspecifickgravitykgreaterkthank1.030kindicateskakdecreasekinkurinekvolumekandkan
kincreasekinkosmolarity,kwhichkiskakmanifestationkofkhypertonickdehydration.
Aknursekinkakcommunitykclinickiskcaringkforkakclientkwhokreportskankincreasekinkthekfreque
ncykofkmigrainekheadaches.kTokhelpkreducekthekriskkforkmigrainekheadaches,kwhichkofkt
hekfollowingkfoodskshouldktheknursekrecommendkthekclientkavoid?k-kAgedkcheese
Foodskthatkcontainktyramine,ksuchkaskagedkcheesekandksausage,kcanktriggerkmigrainek
headaches.
Aknursekiskplanningkteachingkforkakclientkwhokhaskbladderkcancerkandkisktokundergokakcut
aneouskdiversionkprocedurektokestablishkakureterostomy.kWhichkofkthekfollowingkstatem
entskshouldktheknursekincludekinkthekteaching?k-
k"Youkshouldkcutkthekopeningkofkthekskinkbarrierkone-eightkinchkwiderkthankthekstoma."
Thekclientkshouldkcutkthekopeningkofkthekskinkbarrierk0.3kcmk(1/8in)kwiderkthankthekstoma
ktokminimizekirritationkofkthekskinkfromkexposurektokurine.
Aknursekiskprovidingkteachingktokakclientkwhokhaskhypothyroidismkandkiskreceivingklevoth
yroxine.kTheknursekshouldkinstructkthekclientkthatkwhichkofkthekfollowingksupplementskca
nkinterferekwithkthekeffectivenesskofkthekmedication?k-kCalcium
Calciumklimitskthekdevelopmentkofkosteoporosiskinkclientskwhokarekpostmenopausalkan
dkworkskaskankantacid.kCalciumksupplementskcankinterferekwithkthekmetabolismkofkaknu
mberkofkmedications,kincludingklevothyroxine.kTheknursekshouldkinstructkthekclientktoka
voidktakingkcalciumkwithink4khrkofklevothyroxinekadministration.
AknursekiskconductingkankadmissionkhistorykforkakclientkwhokisktokundergokakCTkscankwit
hkankIVkcontrastkagent.kTheknursekshouldkidentifykthatkwhichkofkthekfollowingkfindingskre
quireskfurtherkassessment?k-kHistorykofkasthma
Akclientkwhokhaskakhistorykofkasthmakhaskakgreaterkriskkofkreactingktokthekcontrastkdyekus
edkduringkthekprocedure.kOtherkconditionskthatkcankresultkinkakreactionktokcontrastkmedi
akincludekallergiesktokfoods,ksuchkaskshellfish,keggs,kmilk,kandkchocolate.
AknursekinkankICUkiskassessingkakclientkwhokhaskaktraumatickbrainkinjury.kWhichkofkthekfoll
owingkfindingskshouldktheknursekidentifykaskakcomponentkofkCushing'sktriad?k-
kBradycardia
Akclientkwhokhaskincreasedkintracranialkpressurekfromkaktraumatickbrainkinjurykcankdevel
opkbradycardia,kwhichkiskonekcomponentkofkCushing'sktriad.kThekother
,componentskofkCushing'sktriadkarekseverekhypertensionkandkakwidenedkpulsekpressure.
Aknursekiskplanningktokirrigatekandkdresskakclean,kgranulatingkwoundkforkakclientkwhokh
askakpressurekinjury.kWhichkofkthekfollowingkactionskshouldktheknursektake?k-kUsekak30-
mLksyringe
Theknursekshouldkusekak30-mLktok60-mLksyringekwithkank18-kork19-
kgaugekcatheterktokdeliverkthekidealkpressurekofk8kpoundskperksquarekinchk(psi)kwhenkirri
gatingkakwound.kTokmaintainkhealthykgranulationktissue,kthekwoundkirrigationkshouldkbek
deliveredkatkbetweenk4kandk15kpsi.
Aknursekinkankemergencykdepartmentkiskreviewingkthekprovider'skprescriptionskforkakclie
ntkwhoksustainedkakrattlesnakekbitektoktheklowerkleg.kWhichkofkthekfollowingkprescription
skshouldkthekexpect?k-kAdministerkankopioidkanalgesicktokthekclient.
Theknursekshouldkexpectkakprescriptionkforkankopioidkanalgesicktokpromotekcomfortkfollo
wingkakrattlesnakekbite.
Aknursekiskreviewingkthekhealthkrecordkofkakclientkwhokiskscheduledkforkallergykskinktesti
ng.kTheknursekshouldkpostponekthektestingkandkreportktokthekproviderkwhichkofkthekfollo
wingkfindings?k(Clickkonkthek"Exhibit"kbuttonkforkadditionalkinformationkaboutkthekclient).
k-kCurrentkmedications
Theknursekshouldkreviewkthekclient'skmedicationkrecordkandkidentifykmedications,kinclu
dingkACEkinhibitors,kbetakblockers,ktheophylline,knifedipine,kandkglucocorticoids,ksuchka
skprednisone,kthatkcankalterkthekallergykskinktestkresults.kThesekmedicationskcankdiminis
hkthekclient'skreactionktokthekallergens.kTheknursekshouldknotifykthekproviderkandkinstruct
kthekclientktokdiscontinuekprednisonekfork2kweekskbeforekallergykskinktesting.
Aknursekiskakcaringkforkakclientkwhokiskonkbedkrestkandkhaskaknewkprescriptionkforkenoxa
parinksubcutaneous.kWhichkofkthekfollowingkactionskshouldktheknursektake?k-
kInjectkthekmedicationkintokthekanterolateralkabdominalkwall.
Theknursekshouldkinjectkthekmedicationkintokthekanterolateralkorkposterolateralkabdomin
alkwallktokenhancekmedicationkabsorptionkandkpreventkhematomakformation.
AknursekiskcaringkforkakclientkwhokhaskakstagekIIIkpressurekinjury.kWhichkifkthekfollowingkf
indingskcontributektokdelayedkwoundkhealing?k-kUrinekoutputk25kmL/hr
Urinarykoutputkreflectskfluidkstatus.kInadequatekurinekoutputkcankindicatekdehydration,kw
hichkcankdelaykwoundkhealing.
Aknursekiskcaringkforkakclientkwhokhaskaknewkprescriptionkforktotalkparenteralknutritionk(T
PN).kThekclientkisktokreceivek2,000kkcalkperkday.kThekTPNksolutionkhask500kcal/L.kThekI
VkpumpkshouldkbeksetkatkhowkmanykmL/hr?k(Roundingktoktheknearestkwholeknumber.)k-
k167kmL/hr
, Aknursekiskteachingkakclientkwhokhaskakfamilykhistorykofkcolorectalkcancer.kTokhelpkmitiga
tekthiskrisk,kwhichkofkthekfollowingkdietarykalterationskshouldktheknursekrecommend?k-
kAddkcabbagektokthekdiet.
Tokhelpkreducekthekriskkforkcolorectalkcancer,kthekclientkshouldkconsumekakdietkthatkiskhi
ghkinkfiber,klowkinkfat,kandklowkinkrefinedkcarbohydrates.kBrassicakvegetablesksuchkaskc
abbage,kcauliflower,kandkbroccoli,karekhighkinkfiber.
Aknursekiskcaringkforkakclientkwhokhaskakprescriptionkforksilverksulfadiazinekcreamktokbek
appliedktokherkburnkwounds.kTheknursekshouldkevaluatekthekclientkforkwhichkofkthekfollo
wingklaboratorykfindings?k-kLeukopenia
Transientkleukopeniakiskankadversekeffectkofksilverksulfadiazine.
Aknursekiskteachingkakclientkwithksystemickerythematosuskwhokhaskaknewkprescriptionkfo
rkprednisone.kTheknursekshouldkinstructkthekclientktokmonitorkforkwhichkofkthekfollowingka
dversekeffectskofkthiskmedication?k-kInfection
Theknursekshouldkinstructkthekclientktokavoidkcontactkwithkpeoplekwhokarekillkandkmonitork
forkmanifestationskofkankinfectionksuchkaskakfeverkorkaksorekthroat.
Prednisonekcanksuppresskthekclient'skimmunekresponsekandkmaskkthekmanifestationskof
kankinfection.
Aknursekiskprovidingkpreoperativekteachingktokakclientkwhokwillkundergokaktotalklaryngec
tomy.kWhichkofkthekfollowingkstatementskindicateskthatkthekclientkunderstandskthekimp
actkofktheksurgery?k-
k"IkunderstandkthatkIkwillkhavekakpermanentktracheostomykafterktheksurgery."
Withkakpartialklaryngectomy,kthektracheostomykisktemporary.kThiskclientkwillkhavekaktotalk
laryngectomy,ksokthektracheostomykwillkbekpermanent.
Aknursekiskassessingkakclientkwhokhasksystemickscleroderma.kWhichkofkthekfollowingkfin
dingskshouldktheknursekexpect?k-kFingerkcontractures
Sclerodermakiskakchronickdiseasekthatkcankcausekthickening,khardening,korktighteningko
fkthekskin,kbloodkvessels,kandkinternalkorgans.kTherekarek2ktypeskofkscleroderma:klocali
zedkscleroderma,kwhichkmainlykaffectskthekskin,kandksystemickscleroderma,kwhichkcank
affectkinternalkorgans.kManifestationskincludekskinkchanges,kRaynaud'skphenomenon,k
arthritis,kmusclekweakness,kandkdrykmucouskmembranes.kWithksclerodermakthekbodyk
produceskandkdepositsktookmuchkcollagen,kcausingkthickeningkandkhardening.kInkadditi
onktokthekclient'skskinkandksubcutaneousktissueskbecomingkincreasinglykhardkandkrigid,k
thekextremitieskstiffenkandklosekmobility.kContractureskdevelopkwithkadvancedksystemi
cksclerodermakunlesskclientskfollowkakregimenkofkrange-of-motionkandkmuscle-
strengtheningkexercises.
Aknursekiskcaringkforkakclientkwhokhasktracheostomykandkiskreceivingkmechanicalkventila
tion.kWhenktheklow-
pressurekalarmkonkthekventilatorksounds,kitkindicateskwhichkofkthekfollowingktoktheknurse
?k-kAkleakkwithinkthekventilator'skcircuitry
100 %
Ankolderkadultkiskbroughtktokankemergencykdepartmentkbykakfamilykmember.kWhichkofkth
ekfollowingkassessmentkfindingskshouldkcausektheknursektoksuspectkthatkthekclientkhask
hypertonickdehydration?k-kUrinekSpecifickgravityk1.045
Akurinekspecifickgravitykgreaterkthank1.030kindicateskakdecreasekinkurinekvolumekandkan
kincreasekinkosmolarity,kwhichkiskakmanifestationkofkhypertonickdehydration.
Aknursekinkakcommunitykclinickiskcaringkforkakclientkwhokreportskankincreasekinkthekfreque
ncykofkmigrainekheadaches.kTokhelpkreducekthekriskkforkmigrainekheadaches,kwhichkofkt
hekfollowingkfoodskshouldktheknursekrecommendkthekclientkavoid?k-kAgedkcheese
Foodskthatkcontainktyramine,ksuchkaskagedkcheesekandksausage,kcanktriggerkmigrainek
headaches.
Aknursekiskplanningkteachingkforkakclientkwhokhaskbladderkcancerkandkisktokundergokakcut
aneouskdiversionkprocedurektokestablishkakureterostomy.kWhichkofkthekfollowingkstatem
entskshouldktheknursekincludekinkthekteaching?k-
k"Youkshouldkcutkthekopeningkofkthekskinkbarrierkone-eightkinchkwiderkthankthekstoma."
Thekclientkshouldkcutkthekopeningkofkthekskinkbarrierk0.3kcmk(1/8in)kwiderkthankthekstoma
ktokminimizekirritationkofkthekskinkfromkexposurektokurine.
Aknursekiskprovidingkteachingktokakclientkwhokhaskhypothyroidismkandkiskreceivingklevoth
yroxine.kTheknursekshouldkinstructkthekclientkthatkwhichkofkthekfollowingksupplementskca
nkinterferekwithkthekeffectivenesskofkthekmedication?k-kCalcium
Calciumklimitskthekdevelopmentkofkosteoporosiskinkclientskwhokarekpostmenopausalkan
dkworkskaskankantacid.kCalciumksupplementskcankinterferekwithkthekmetabolismkofkaknu
mberkofkmedications,kincludingklevothyroxine.kTheknursekshouldkinstructkthekclientktoka
voidktakingkcalciumkwithink4khrkofklevothyroxinekadministration.
AknursekiskconductingkankadmissionkhistorykforkakclientkwhokisktokundergokakCTkscankwit
hkankIVkcontrastkagent.kTheknursekshouldkidentifykthatkwhichkofkthekfollowingkfindingskre
quireskfurtherkassessment?k-kHistorykofkasthma
Akclientkwhokhaskakhistorykofkasthmakhaskakgreaterkriskkofkreactingktokthekcontrastkdyekus
edkduringkthekprocedure.kOtherkconditionskthatkcankresultkinkakreactionktokcontrastkmedi
akincludekallergiesktokfoods,ksuchkaskshellfish,keggs,kmilk,kandkchocolate.
AknursekinkankICUkiskassessingkakclientkwhokhaskaktraumatickbrainkinjury.kWhichkofkthekfoll
owingkfindingskshouldktheknursekidentifykaskakcomponentkofkCushing'sktriad?k-
kBradycardia
Akclientkwhokhaskincreasedkintracranialkpressurekfromkaktraumatickbrainkinjurykcankdevel
opkbradycardia,kwhichkiskonekcomponentkofkCushing'sktriad.kThekother
,componentskofkCushing'sktriadkarekseverekhypertensionkandkakwidenedkpulsekpressure.
Aknursekiskplanningktokirrigatekandkdresskakclean,kgranulatingkwoundkforkakclientkwhokh
askakpressurekinjury.kWhichkofkthekfollowingkactionskshouldktheknursektake?k-kUsekak30-
mLksyringe
Theknursekshouldkusekak30-mLktok60-mLksyringekwithkank18-kork19-
kgaugekcatheterktokdeliverkthekidealkpressurekofk8kpoundskperksquarekinchk(psi)kwhenkirri
gatingkakwound.kTokmaintainkhealthykgranulationktissue,kthekwoundkirrigationkshouldkbek
deliveredkatkbetweenk4kandk15kpsi.
Aknursekinkankemergencykdepartmentkiskreviewingkthekprovider'skprescriptionskforkakclie
ntkwhoksustainedkakrattlesnakekbitektoktheklowerkleg.kWhichkofkthekfollowingkprescription
skshouldkthekexpect?k-kAdministerkankopioidkanalgesicktokthekclient.
Theknursekshouldkexpectkakprescriptionkforkankopioidkanalgesicktokpromotekcomfortkfollo
wingkakrattlesnakekbite.
Aknursekiskreviewingkthekhealthkrecordkofkakclientkwhokiskscheduledkforkallergykskinktesti
ng.kTheknursekshouldkpostponekthektestingkandkreportktokthekproviderkwhichkofkthekfollo
wingkfindings?k(Clickkonkthek"Exhibit"kbuttonkforkadditionalkinformationkaboutkthekclient).
k-kCurrentkmedications
Theknursekshouldkreviewkthekclient'skmedicationkrecordkandkidentifykmedications,kinclu
dingkACEkinhibitors,kbetakblockers,ktheophylline,knifedipine,kandkglucocorticoids,ksuchka
skprednisone,kthatkcankalterkthekallergykskinktestkresults.kThesekmedicationskcankdiminis
hkthekclient'skreactionktokthekallergens.kTheknursekshouldknotifykthekproviderkandkinstruct
kthekclientktokdiscontinuekprednisonekfork2kweekskbeforekallergykskinktesting.
Aknursekiskakcaringkforkakclientkwhokiskonkbedkrestkandkhaskaknewkprescriptionkforkenoxa
parinksubcutaneous.kWhichkofkthekfollowingkactionskshouldktheknursektake?k-
kInjectkthekmedicationkintokthekanterolateralkabdominalkwall.
Theknursekshouldkinjectkthekmedicationkintokthekanterolateralkorkposterolateralkabdomin
alkwallktokenhancekmedicationkabsorptionkandkpreventkhematomakformation.
AknursekiskcaringkforkakclientkwhokhaskakstagekIIIkpressurekinjury.kWhichkifkthekfollowingkf
indingskcontributektokdelayedkwoundkhealing?k-kUrinekoutputk25kmL/hr
Urinarykoutputkreflectskfluidkstatus.kInadequatekurinekoutputkcankindicatekdehydration,kw
hichkcankdelaykwoundkhealing.
Aknursekiskcaringkforkakclientkwhokhaskaknewkprescriptionkforktotalkparenteralknutritionk(T
PN).kThekclientkisktokreceivek2,000kkcalkperkday.kThekTPNksolutionkhask500kcal/L.kThekI
VkpumpkshouldkbeksetkatkhowkmanykmL/hr?k(Roundingktoktheknearestkwholeknumber.)k-
k167kmL/hr
, Aknursekiskteachingkakclientkwhokhaskakfamilykhistorykofkcolorectalkcancer.kTokhelpkmitiga
tekthiskrisk,kwhichkofkthekfollowingkdietarykalterationskshouldktheknursekrecommend?k-
kAddkcabbagektokthekdiet.
Tokhelpkreducekthekriskkforkcolorectalkcancer,kthekclientkshouldkconsumekakdietkthatkiskhi
ghkinkfiber,klowkinkfat,kandklowkinkrefinedkcarbohydrates.kBrassicakvegetablesksuchkaskc
abbage,kcauliflower,kandkbroccoli,karekhighkinkfiber.
Aknursekiskcaringkforkakclientkwhokhaskakprescriptionkforksilverksulfadiazinekcreamktokbek
appliedktokherkburnkwounds.kTheknursekshouldkevaluatekthekclientkforkwhichkofkthekfollo
wingklaboratorykfindings?k-kLeukopenia
Transientkleukopeniakiskankadversekeffectkofksilverksulfadiazine.
Aknursekiskteachingkakclientkwithksystemickerythematosuskwhokhaskaknewkprescriptionkfo
rkprednisone.kTheknursekshouldkinstructkthekclientktokmonitorkforkwhichkofkthekfollowingka
dversekeffectskofkthiskmedication?k-kInfection
Theknursekshouldkinstructkthekclientktokavoidkcontactkwithkpeoplekwhokarekillkandkmonitork
forkmanifestationskofkankinfectionksuchkaskakfeverkorkaksorekthroat.
Prednisonekcanksuppresskthekclient'skimmunekresponsekandkmaskkthekmanifestationskof
kankinfection.
Aknursekiskprovidingkpreoperativekteachingktokakclientkwhokwillkundergokaktotalklaryngec
tomy.kWhichkofkthekfollowingkstatementskindicateskthatkthekclientkunderstandskthekimp
actkofktheksurgery?k-
k"IkunderstandkthatkIkwillkhavekakpermanentktracheostomykafterktheksurgery."
Withkakpartialklaryngectomy,kthektracheostomykisktemporary.kThiskclientkwillkhavekaktotalk
laryngectomy,ksokthektracheostomykwillkbekpermanent.
Aknursekiskassessingkakclientkwhokhasksystemickscleroderma.kWhichkofkthekfollowingkfin
dingskshouldktheknursekexpect?k-kFingerkcontractures
Sclerodermakiskakchronickdiseasekthatkcankcausekthickening,khardening,korktighteningko
fkthekskin,kbloodkvessels,kandkinternalkorgans.kTherekarek2ktypeskofkscleroderma:klocali
zedkscleroderma,kwhichkmainlykaffectskthekskin,kandksystemickscleroderma,kwhichkcank
affectkinternalkorgans.kManifestationskincludekskinkchanges,kRaynaud'skphenomenon,k
arthritis,kmusclekweakness,kandkdrykmucouskmembranes.kWithksclerodermakthekbodyk
produceskandkdepositsktookmuchkcollagen,kcausingkthickeningkandkhardening.kInkadditi
onktokthekclient'skskinkandksubcutaneousktissueskbecomingkincreasinglykhardkandkrigid,k
thekextremitieskstiffenkandklosekmobility.kContractureskdevelopkwithkadvancedksystemi
cksclerodermakunlesskclientskfollowkakregimenkofkrange-of-motionkandkmuscle-
strengtheningkexercises.
Aknursekiskcaringkforkakclientkwhokhasktracheostomykandkiskreceivingkmechanicalkventila
tion.kWhenktheklow-
pressurekalarmkonkthekventilatorksounds,kitkindicateskwhichkofkthekfollowingktoktheknurse
?k-kAkleakkwithinkthekventilator'skcircuitry
