ATI Medsurg A and B
A nurse is preparing to transfer a client who can bear weight on one leg from the
bed to a chair. After securing a safe environment, which of the following actions
should the nurse take next? - CORRECT ANSWER-Assess the client for
orthostatic hypotension
The first action the nurse should take using the nursing process is to assess the
client. The nurse should determine the client's risk for falling or fainting during the
transfer by assisting her to sit and dangle her feet on the side of the bed. The
nurse should assess her for dizziness and a significant drop in blood pressure
before assisting her to stand and transfer into the chair.
A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to
a client. Which of the following actions should the nurse take? - CORRECT
ANSWER-Gently shake the container of medication prior to administration.
A nurse is teaching a group of staff nurses about the use of essential oils for
aromatherapy. The nurse should
include in the teaching that this therapy might be contraindicated for which of the
following clients? - CORRECT ANSWER-A client who has asthma
Some essential oils can cause bronchospasm; therefore, the nurse should
consult the client's provider before using this therapy for a client who has asthma.
A nurse in a clinic is caring for a middle adult client who states, "The doctor says
that, since I am at an average risk for colon cancer, I should have routine
screening. What does that involve?" Which of the following responses should the
nurse make? - CORRECT ANSWER-"You should have a fecal occult blood test
every year."
A nurse is planning an educational program for a group of older adults at a senior
living center. Which of the
following recommendations should the nurse include? - CORRECT
ANSWER-"You should receive a pneumococcal vaccine when you are 65 years
old."
,Diagnostic Results
Week 1:
Hct 42% (37% to 47%)
Hgb 15 g/dL (12 g/dL to 16 g/dL)
WBC count 8,000/mm3 (5,000 to 10,000/mm3)
Platelet count 350,000/mm3 (150,000 to
400,000/mm3)
Potassium 3.7 mEq/L (3.5 to 5 mEq/L)
Week 2:
Hct 37% (37% to 47%)
Hgb 12 g/dL (12 g/dL to 16 g/dL)
WBC count 6,000/mm3 (5,000 to 10,000/mm3)
Platelet count 100,000/mm3 (150,000 to
400,000/mm3)
Potassium 3.6 mEq/L (3.5 to 5 mEq/L)
The client is at risk for
by the client's
as evidenced - CORRECT ANSWER-Bleeding AEB platelet count
A charge nurse is discussing the responsibility of nurses caring for clients who
have a Clostridium difficile infection.
Which of the following information should the nurse include in the teaching? -
CORRECT ANSWER-Have family members wear a gown and gloves when
visiting.
A nurse is providing discharge teaching for a client who has a new prescription
for a home oxygen concentrator.
Which of the following instructions should the nurse provide to the client and his
family? (Select all that apply.) - CORRECT ANSWER-Check the cord routinely
for frays or tearing.
Consider purchasing a generator for power backup
Observe for signs of hypoxia
A nurse is administering IV fluids to a client. When monitoring for adverse effects,
which of the following
,assessments should the nurse identify as the priority? - CORRECT
ANSWER-Auscultate lung sounds
The priority assessment the nurse should make when using the airway,
breathing, circulation approach to client care is auscultating lung sounds to
monitor for fluid volume excess, a complication of IV therapy. Manifestations of
fluid volume excess include moist crackles in lung fields, dyspnea, and shortness
of breath.
a nurse in an acute care facility is preparing a discharge summary for a client
who is transferring to a long-term care facility. Which of the following
documentation should the nurse include? - CORRECT ANSWER-Current
Medications
Rationale:
The nurse should include the client's medications in the discharge summary to
ensure client safety and continuity of care.
A nurse is caring for a client who has decreased mobility. Which of the following
actions should the nurse take to
decrease the client's risk of developing plantar flexion contractures? - CORRECT
ANSWER-Apply an ankle foot orthotic device to the clients feet
Rationale: The nurse should use a device to maintain dorsiflexion, such as an
ankle- foot orthotic device or a footboard placed perpendicular to the mattress
A nurse is preparing to delegate client care tasks to an assistive personnel (AP).
Which of the following tasks should
the nurse delegate? - CORRECT ANSWER-Ambulating a client who is
postoperative
Ambulating a client is within the range of function of an AP. The nurse can
delegate tasks to the AP that do not require
special skills, assessment, or teaching.
A charge nurse is observing a newly licensed nurse prepare a sterile field for a
dressing change. Which of the
, following actions by the newly licensed nurse requires intervention by the charge
nurse? - CORRECT ANSWER-The newly licensed nurse places the cap of a
bottle of sterile saline solution on the sterile field.
The newly licensed nurse should place the cap with the sterile side up on a clean
surface because the outer edges are
unsterile and will contaminate the sterile field
A nurse is caring for a client who reports difficulty falling asleep. Which of the
following recommendations should
the nurse make? - CORRECT ANSWER-maintain a consistent time to wake up
each day
The client should maintain a consistent time for waking up and going to sleep.
This helps to establish an internal sense of
sleep and waking on a daily basis and helps to maintain it over time. This will
help promote sleep for the client.
A client who is nonambulatory notifies the nurse that his trash can is on fire. After
the nurse confirms the presence
of the fire, which of the following actions should the nurse take next? -
CORRECT ANSWER-evacuate the client
According to the RACE mnemonic, the first action in response to a fire is to
rescue the clients, moving them to a safe area.
A nurse is admitting a client who reports experiencing a sore
throat, productive cough, and fever for the past 3 days.
The patient is dx with pneumonia
The nurse is reviewing the client's medical record. Which
of the following actions should the nurse take?
Select all that apply. - CORRECT ANSWER-Request a prescription for an
antibiotic medication.
Wear mask within 3 feet of the client
Initiate droplet precaution
A nurse is preparing to transfer a client who can bear weight on one leg from the
bed to a chair. After securing a safe environment, which of the following actions
should the nurse take next? - CORRECT ANSWER-Assess the client for
orthostatic hypotension
The first action the nurse should take using the nursing process is to assess the
client. The nurse should determine the client's risk for falling or fainting during the
transfer by assisting her to sit and dangle her feet on the side of the bed. The
nurse should assess her for dizziness and a significant drop in blood pressure
before assisting her to stand and transfer into the chair.
A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to
a client. Which of the following actions should the nurse take? - CORRECT
ANSWER-Gently shake the container of medication prior to administration.
A nurse is teaching a group of staff nurses about the use of essential oils for
aromatherapy. The nurse should
include in the teaching that this therapy might be contraindicated for which of the
following clients? - CORRECT ANSWER-A client who has asthma
Some essential oils can cause bronchospasm; therefore, the nurse should
consult the client's provider before using this therapy for a client who has asthma.
A nurse in a clinic is caring for a middle adult client who states, "The doctor says
that, since I am at an average risk for colon cancer, I should have routine
screening. What does that involve?" Which of the following responses should the
nurse make? - CORRECT ANSWER-"You should have a fecal occult blood test
every year."
A nurse is planning an educational program for a group of older adults at a senior
living center. Which of the
following recommendations should the nurse include? - CORRECT
ANSWER-"You should receive a pneumococcal vaccine when you are 65 years
old."
,Diagnostic Results
Week 1:
Hct 42% (37% to 47%)
Hgb 15 g/dL (12 g/dL to 16 g/dL)
WBC count 8,000/mm3 (5,000 to 10,000/mm3)
Platelet count 350,000/mm3 (150,000 to
400,000/mm3)
Potassium 3.7 mEq/L (3.5 to 5 mEq/L)
Week 2:
Hct 37% (37% to 47%)
Hgb 12 g/dL (12 g/dL to 16 g/dL)
WBC count 6,000/mm3 (5,000 to 10,000/mm3)
Platelet count 100,000/mm3 (150,000 to
400,000/mm3)
Potassium 3.6 mEq/L (3.5 to 5 mEq/L)
The client is at risk for
by the client's
as evidenced - CORRECT ANSWER-Bleeding AEB platelet count
A charge nurse is discussing the responsibility of nurses caring for clients who
have a Clostridium difficile infection.
Which of the following information should the nurse include in the teaching? -
CORRECT ANSWER-Have family members wear a gown and gloves when
visiting.
A nurse is providing discharge teaching for a client who has a new prescription
for a home oxygen concentrator.
Which of the following instructions should the nurse provide to the client and his
family? (Select all that apply.) - CORRECT ANSWER-Check the cord routinely
for frays or tearing.
Consider purchasing a generator for power backup
Observe for signs of hypoxia
A nurse is administering IV fluids to a client. When monitoring for adverse effects,
which of the following
,assessments should the nurse identify as the priority? - CORRECT
ANSWER-Auscultate lung sounds
The priority assessment the nurse should make when using the airway,
breathing, circulation approach to client care is auscultating lung sounds to
monitor for fluid volume excess, a complication of IV therapy. Manifestations of
fluid volume excess include moist crackles in lung fields, dyspnea, and shortness
of breath.
a nurse in an acute care facility is preparing a discharge summary for a client
who is transferring to a long-term care facility. Which of the following
documentation should the nurse include? - CORRECT ANSWER-Current
Medications
Rationale:
The nurse should include the client's medications in the discharge summary to
ensure client safety and continuity of care.
A nurse is caring for a client who has decreased mobility. Which of the following
actions should the nurse take to
decrease the client's risk of developing plantar flexion contractures? - CORRECT
ANSWER-Apply an ankle foot orthotic device to the clients feet
Rationale: The nurse should use a device to maintain dorsiflexion, such as an
ankle- foot orthotic device or a footboard placed perpendicular to the mattress
A nurse is preparing to delegate client care tasks to an assistive personnel (AP).
Which of the following tasks should
the nurse delegate? - CORRECT ANSWER-Ambulating a client who is
postoperative
Ambulating a client is within the range of function of an AP. The nurse can
delegate tasks to the AP that do not require
special skills, assessment, or teaching.
A charge nurse is observing a newly licensed nurse prepare a sterile field for a
dressing change. Which of the
, following actions by the newly licensed nurse requires intervention by the charge
nurse? - CORRECT ANSWER-The newly licensed nurse places the cap of a
bottle of sterile saline solution on the sterile field.
The newly licensed nurse should place the cap with the sterile side up on a clean
surface because the outer edges are
unsterile and will contaminate the sterile field
A nurse is caring for a client who reports difficulty falling asleep. Which of the
following recommendations should
the nurse make? - CORRECT ANSWER-maintain a consistent time to wake up
each day
The client should maintain a consistent time for waking up and going to sleep.
This helps to establish an internal sense of
sleep and waking on a daily basis and helps to maintain it over time. This will
help promote sleep for the client.
A client who is nonambulatory notifies the nurse that his trash can is on fire. After
the nurse confirms the presence
of the fire, which of the following actions should the nurse take next? -
CORRECT ANSWER-evacuate the client
According to the RACE mnemonic, the first action in response to a fire is to
rescue the clients, moving them to a safe area.
A nurse is admitting a client who reports experiencing a sore
throat, productive cough, and fever for the past 3 days.
The patient is dx with pneumonia
The nurse is reviewing the client's medical record. Which
of the following actions should the nurse take?
Select all that apply. - CORRECT ANSWER-Request a prescription for an
antibiotic medication.
Wear mask within 3 feet of the client
Initiate droplet precaution
