ATI NUR265 : Adult Medical-Surgical Nursing | Comprehensive Test Bank with Correct answers and
Rationales
A nurse is caring for a client who is 24 hours postop following a total hip arthroplasty. Which of
the following action should the nurse take? - correct answer Maintain abduction of the affected
extremity
A nurse is providing teaching to a client who is scheduled for a bronchoscopy. Which of the
following statements should the nurse include in the teaching? - correct answer "You will not be
able to eat or drink after the procedure until you are able to cough."
- A client who had a bronchoscopy received a local anesthetic that can suppress the cough
reflex. The cough reflex protects the client from aspirating fluids or food. Therefore, the client
should not eat or drink until the cough reflex returns.
A nurse is assessing a clients understanding of a surgical procedure prior to witnessing their
signature on the informed consent form. The nurse determines that the client does not
understand what the procedure will involve. Which of the following action should the nurse
take? - correct answer Contact the provider who will be performing the procedure
A nurse is providing discharge teaching to a client who has COPD. Which of the following
instruction should the nurse include in the teaching? - correct answer Consume a diet that is
high in calories
A nurse is providing teaching about dietary options for a client who has cholithiasis which of the
following statements should the nurse include in the teaching - correct answer Select desserts,
such as angel food cake
A nurse is monitoring a client who has a traumatic brain injury, which of the following findings
should the nurse identify as a manifestation of Cushing's triad - correct answer Increase in
blood pressure from 130/80 to 180/100
A nurse is teaching a client who has a new diagnosis of type one diabetes mellitus, which of the
following statement by the client indicates an understanding of the teaching - correct answer I
am aware that my diabetes is caused by an auto immune disorder
A nurse is caring for a client who has a small bowel obstruction and an NG tube in place which
of the following action should the nurse take - correct answer Maintain low intermittent suction
A nurse is assessing a client who has a chest tube connected to a closed water seal drainage
system which of the following findings should the nurse report to the provider - correct answer
CONSTANT BUBBLING IN THE WATER SEAL CHAMBER.
- Constant bubbling in the water seal chamber can be an indication of an air leak, which is
caused by a disruption in the system such as a loose connection. Pulmonary air leaks create
, ATI NUR265 : Adult Medical-Surgical Nursing | Comprehensive Test Bank with Correct answers and
Rationales
intermittent bubbling that is synchronous with respiration. This finding should be reported to
the provider immediately.
A nurse is providing teaching for a client who has neutropenia and is receiving chemotherapy,
which of the following client statements, indicates an understanding of the teaching? Select all
that apply. - correct answer I will avoid crowds, and I will take my temperature daily
I nurse is preparing to administer propranolol to several clients. For which of the following
clients to the nurse clarify the prescription with the provider before administration. - correct
answer A client has a history of asthma
Nurses analyzing the ABG results of a client who is in respiratory acidosis, which of the following
mechanisms to the nurse, identify as responsible for this acid-base imbalance - correct answer
Retention of carbon dioxide
A nurse is planning care for a client who is tuberculosis which of the following precautions
should the nurse implement for this client - correct answer Airborne precautions
A nurse is caring for a client who is three hours, post operative, and exhibiting signs of
hypokalemia which of the following findings. Should the nurse identify as a manifestation of
hypovolemia. - correct answer Rapid pulse rate
A nurse is caring for a client who has a prescription for lactated ringers by continuous IV infusion
to replace output from an NG tube which of the following findings should indicate to the nurse
that this therapy is effective - correct answer A urine specific gravity of 1.020
A nursing emergency department is caring for a client who's confused, has a temperature of
104°F, a blood pressure of 74/52 and a diagnosis of exertional heat stroke which of the following
action should the nurse take first - correct answer Administer oxygen using a high concentration
mask
A nurse is caring for a client who has a chronic venous insufficiency, which of the following areas
should the nurse assessed for the presence of a venous ulcer - correct answer A, is correct
A nurse is providing teaching to a client about strategies to manage menopausal symptoms
which of the following instruction should the nurse include in the teaching - correct answer Use
water based lubricant during intercourse to reduce discomfort
A nurse is teaching a client about self management of their halo fixator device, which of the
following information should the nurse include in the teaching - correct answer Place a small
pillow under the head while lying supine
Home health nurse is inspecting the clients residence for electrical hazards as part of the
agencies quality improvement plan which of the following findings should the nurse identify as
a safety hazard - correct answer An IV pump is plugged into an outlet near sink
Rationales
A nurse is caring for a client who is 24 hours postop following a total hip arthroplasty. Which of
the following action should the nurse take? - correct answer Maintain abduction of the affected
extremity
A nurse is providing teaching to a client who is scheduled for a bronchoscopy. Which of the
following statements should the nurse include in the teaching? - correct answer "You will not be
able to eat or drink after the procedure until you are able to cough."
- A client who had a bronchoscopy received a local anesthetic that can suppress the cough
reflex. The cough reflex protects the client from aspirating fluids or food. Therefore, the client
should not eat or drink until the cough reflex returns.
A nurse is assessing a clients understanding of a surgical procedure prior to witnessing their
signature on the informed consent form. The nurse determines that the client does not
understand what the procedure will involve. Which of the following action should the nurse
take? - correct answer Contact the provider who will be performing the procedure
A nurse is providing discharge teaching to a client who has COPD. Which of the following
instruction should the nurse include in the teaching? - correct answer Consume a diet that is
high in calories
A nurse is providing teaching about dietary options for a client who has cholithiasis which of the
following statements should the nurse include in the teaching - correct answer Select desserts,
such as angel food cake
A nurse is monitoring a client who has a traumatic brain injury, which of the following findings
should the nurse identify as a manifestation of Cushing's triad - correct answer Increase in
blood pressure from 130/80 to 180/100
A nurse is teaching a client who has a new diagnosis of type one diabetes mellitus, which of the
following statement by the client indicates an understanding of the teaching - correct answer I
am aware that my diabetes is caused by an auto immune disorder
A nurse is caring for a client who has a small bowel obstruction and an NG tube in place which
of the following action should the nurse take - correct answer Maintain low intermittent suction
A nurse is assessing a client who has a chest tube connected to a closed water seal drainage
system which of the following findings should the nurse report to the provider - correct answer
CONSTANT BUBBLING IN THE WATER SEAL CHAMBER.
- Constant bubbling in the water seal chamber can be an indication of an air leak, which is
caused by a disruption in the system such as a loose connection. Pulmonary air leaks create
, ATI NUR265 : Adult Medical-Surgical Nursing | Comprehensive Test Bank with Correct answers and
Rationales
intermittent bubbling that is synchronous with respiration. This finding should be reported to
the provider immediately.
A nurse is providing teaching for a client who has neutropenia and is receiving chemotherapy,
which of the following client statements, indicates an understanding of the teaching? Select all
that apply. - correct answer I will avoid crowds, and I will take my temperature daily
I nurse is preparing to administer propranolol to several clients. For which of the following
clients to the nurse clarify the prescription with the provider before administration. - correct
answer A client has a history of asthma
Nurses analyzing the ABG results of a client who is in respiratory acidosis, which of the following
mechanisms to the nurse, identify as responsible for this acid-base imbalance - correct answer
Retention of carbon dioxide
A nurse is planning care for a client who is tuberculosis which of the following precautions
should the nurse implement for this client - correct answer Airborne precautions
A nurse is caring for a client who is three hours, post operative, and exhibiting signs of
hypokalemia which of the following findings. Should the nurse identify as a manifestation of
hypovolemia. - correct answer Rapid pulse rate
A nurse is caring for a client who has a prescription for lactated ringers by continuous IV infusion
to replace output from an NG tube which of the following findings should indicate to the nurse
that this therapy is effective - correct answer A urine specific gravity of 1.020
A nursing emergency department is caring for a client who's confused, has a temperature of
104°F, a blood pressure of 74/52 and a diagnosis of exertional heat stroke which of the following
action should the nurse take first - correct answer Administer oxygen using a high concentration
mask
A nurse is caring for a client who has a chronic venous insufficiency, which of the following areas
should the nurse assessed for the presence of a venous ulcer - correct answer A, is correct
A nurse is providing teaching to a client about strategies to manage menopausal symptoms
which of the following instruction should the nurse include in the teaching - correct answer Use
water based lubricant during intercourse to reduce discomfort
A nurse is teaching a client about self management of their halo fixator device, which of the
following information should the nurse include in the teaching - correct answer Place a small
pillow under the head while lying supine
Home health nurse is inspecting the clients residence for electrical hazards as part of the
agencies quality improvement plan which of the following findings should the nurse identify as
a safety hazard - correct answer An IV pump is plugged into an outlet near sink
