Med surg- proctored ATI exam with
| | | | | |
verified answers |
An |older |adult |is |brought |to |an |emergency |department |by |a |family |member. |Which |of |the |
following |assessment |findings |should |cause |the |nurse |to |suspect |that |the |client |has |hypertonic
|dehydration? |- | |correct |answers |Urine |Specific |gravity |1.045 |
A |urine |specific |gravity |greater |than |1.030 |indicates |a |decrease |in |urine |volume |and |an |
increase |in |osmolarity, |which |is |a |manifestation |of |hypertonic |dehydration.
A |nurse |in |a |community |clinic |is |caring |for |a |client |who |reports |an |increase |in |the |frequency |
of |migraine |headaches. |To |help |reduce |the |risk |for |migraine |headaches, |which |of |the |following
|foods |should |the |nurse |recommend |the |client |avoid? |- | |correct |answers |Aged |cheese
Foods |that |contain |tyramine, |such |as |aged |cheese |and |sausage, |can |trigger |migraine |
headaches.
A |nurse |is |planning |teaching |for |a |client |who |has |bladder |cancer |and |is |to |undergo |a |
cutaneous |diversion |procedure |to |establish |a |ureterostomy. |Which |of |the |following |statements
|should |the |nurse |include |in |the |teaching? |- | |correct |answers |"You |should |cut |the |opening |of |
the |skin |barrier |one-eight |inch |wider |than |the |stoma." |
The |client |should |cut |the |opening |of |the |skin |barrier |0.3 |cm |(1/8in) |wider |than |the |stoma |to |
minimize |irritation |of |the |skin |from |exposure |to |urine.
A |nurse |is |providing |teaching |to |a |client |who |has |hypothyroidism |and |is |receiving |
levothyroxine. |The |nurse |should |instruct |the |client |that |which |of |the |following |supplements |
can |interfere |with |the |effectiveness |of |the |medication? |- | |correct |answers |Calcium
,Calcium |limits |the |development |of |osteoporosis |in |clients |who |are |postmenopausal |and |works
|as |an |antacid. |Calcium |supplements |can |interfere |with |the |metabolism |of |a |number |of |
medications, |including |levothyroxine. |The |nurse |should |instruct |the |client |to |avoid |taking |
calcium |within |4 |hr |of |levothyroxine |administration.
A |nurse |is |conducting |an |admission |history |for |a |client |who |is |to |undergo |a |CT |scan |with |an |IV
|contrast |agent. |The |nurse |should |identify |that |which |of |the |following |findings |requires |further
|assessment? |- | |correct |answers |History |of |asthma |
A |client |who |has |a |history |of |asthma |has |a |greater |risk |of |reacting |to |the |contrast |dye |used |
during |the |procedure. |Other |conditions |that |can |result |in |a |reaction |to |contrast |media |include |
allergies |to |foods, |such |as |shellfish, |eggs, |milk, |and |chocolate.
A |nurse |in |an |ICU |is |assessing |a |client |who |has |a |traumatic |brain |injury. |Which |of |the |following
|findings |should |the |nurse |identify |as |a |component |of |Cushing's |triad? |- | |correct |answers |
Bradycardia |
A |client |who |has |increased |intracranial |pressure |from |a |traumatic |brain |injury |can |develop |
bradycardia, |which |is |one |component |of |Cushing's |triad. |The |other |components |of |Cushing's |
triad |are |severe |hypertension |and |a |widened |pulse |pressure.
A |nurse |is |planning |to |irrigate |and |dress |a |clean, |granulating |wound |for |a |client |who |has |a |
pressure |injury. |Which |of |the |following |actions |should |the |nurse |take? |- | |correct |answers |Use |
a |30-mL |syringe |
The |nurse |should |use |a |30-mL |to |60-mL |syringe |with |an |18- |or |19- |gauge |catheter |to |deliver |
the |ideal |pressure |of |8 |pounds |per |square |inch |(psi) |when |irrigating |a |wound. |To |maintain |
healthy |granulation |tissue, |the |wound |irrigation |should |be |delivered |at |between |4 |and |15 |psi.
,A |nurse |in |an |emergency |department |is |reviewing |the |provider's |prescriptions |for |a |client |who
|sustained |a |rattlesnake |bite |to |the |lower |leg. |Which |of |the |following |prescriptions |should |the |
expect? |- | |correct |answers |Administer |an |opioid |analgesic |to |the |client. |
The |nurse |should |expect |a |prescription |for |an |opioid |analgesic |to |promote |comfort |following |a
|rattlesnake |bite.
A |nurse |is |reviewing |the |health |record |of |a |client |who |is |scheduled |for |allergy |skin |testing. |The
|nurse |should |postpone |the |testing |and |report |to |the |provider |which |of |the |following |findings?
|(Click |on |the |"Exhibit" |button |for |additional |information |about |the |client). |- | |correct |answers |
Current |medications |
The |nurse |should |review |the |client's |medication |record |and |identify |medications, |including |
ACE |inhibitors, |beta |blockers, |theophylline, |nifedipine, |and |glucocorticoids, |such |as |
prednisone, |that |can |alter |the |allergy |skin |test |results. |These |medications |can |diminish |the |
client's |reaction |to |the |allergens. |The |nurse |should |notify |the |provider |and |instruct |the |client |
to |discontinue |prednisone |for |2 |weeks |before |allergy |skin |testing.
A |nurse |is |a |caring |for |a |client |who |is |on |bed |rest |and |has |a |new |prescription |for |enoxaparin |
subcutaneous. |Which |of |the |following |actions |should |the |nurse |take? |- | |correct |answers |Inject |
the |medication |into |the |anterolateral |abdominal |wall. |
The |nurse |should |inject |the |medication |into |the |anterolateral |or |posterolateral |abdominal |wall
|to |enhance |medication |absorption |and |prevent |hematoma |formation.
A |nurse |is |caring |for |a |client |who |has |a |stage |III |pressure |injury. |Which |if |the |following |findings
|contribute |to |delayed |wound |healing? |- | |correct |answers |Urine |output |25 |mL/hr |
Urinary |output |reflects |fluid |status. |Inadequate |urine |output |can |indicate |dehydration, |which |
can |delay |wound |healing.
, A |nurse |is |caring |for |a |client |who |has |a |new |prescription |for |total |parenteral |nutrition |(TPN). |
The |client |is |to |receive |2,000 |kcal |per |day. |The |TPN |solution |has |500kcal/L. |The |IV |pump |
should |be |set |at |how |many |mL/hr? |(Rounding |to |the |nearest |whole |number.) |- | |correct |
answers |167 |mL/hr
A |nurse |is |teaching |a |client |who |has |a |family |history |of |colorectal |cancer. |To |help |mitigate |this |
risk, |which |of |the |following |dietary |alterations |should |the |nurse |recommend? |- | |correct |
answers |Add |cabbage |to |the |diet. |
To |help |reduce |the |risk |for |colorectal |cancer, |the |client |should |consume |a |diet |that |is |high |in |
fiber, |low |in |fat, |and |low |in |refined |carbohydrates. |Brassica |vegetables |such |as |cabbage, |
cauliflower, |and |broccoli, |are |high |in |fiber.
A |nurse |is |caring |for |a |client |who |has |a |prescription |for |silver |sulfadiazine |cream |to |be |applied
|to |her |burn |wounds. |The |nurse |should |evaluate |the |client |for |which |of |the |following |
laboratory |findings? |- | |correct |answers |Leukopenia |
Transient |leukopenia |is |an |adverse |effect |of |silver |sulfadiazine.
A |nurse |is |teaching |a |client |with |systemic |erythematosus |who |has |a |new |prescription |for |
prednisone. |The |nurse |should |instruct |the |client |to |monitor |for |which |of |the |following |adverse
|effects |of |this |medication? |- | |correct |answers |Infection |
The |nurse |should |instruct |the |client |to |avoid |contact |with |people |who |are |ill |and |monitor |for |
manifestations |of |an |infection |such |as |a |fever |or |a |sore |throat. |Prednisone |can |suppress |the |
client's |immune |response |and |mask |the |manifestations |of |an |infection.
A |nurse |is |providing |preoperative |teaching |to |a |client |who |will |undergo |a |total |laryngectomy. |
Which |of |the |following |statements |indicates |that |the |client |understands |the |impact |of |the |
surgery? |- | |correct |answers |"I |understand |that |I |will |have |a |permanent |tracheostomy |after |the |
surgery." |
| | | | | |
verified answers |
An |older |adult |is |brought |to |an |emergency |department |by |a |family |member. |Which |of |the |
following |assessment |findings |should |cause |the |nurse |to |suspect |that |the |client |has |hypertonic
|dehydration? |- | |correct |answers |Urine |Specific |gravity |1.045 |
A |urine |specific |gravity |greater |than |1.030 |indicates |a |decrease |in |urine |volume |and |an |
increase |in |osmolarity, |which |is |a |manifestation |of |hypertonic |dehydration.
A |nurse |in |a |community |clinic |is |caring |for |a |client |who |reports |an |increase |in |the |frequency |
of |migraine |headaches. |To |help |reduce |the |risk |for |migraine |headaches, |which |of |the |following
|foods |should |the |nurse |recommend |the |client |avoid? |- | |correct |answers |Aged |cheese
Foods |that |contain |tyramine, |such |as |aged |cheese |and |sausage, |can |trigger |migraine |
headaches.
A |nurse |is |planning |teaching |for |a |client |who |has |bladder |cancer |and |is |to |undergo |a |
cutaneous |diversion |procedure |to |establish |a |ureterostomy. |Which |of |the |following |statements
|should |the |nurse |include |in |the |teaching? |- | |correct |answers |"You |should |cut |the |opening |of |
the |skin |barrier |one-eight |inch |wider |than |the |stoma." |
The |client |should |cut |the |opening |of |the |skin |barrier |0.3 |cm |(1/8in) |wider |than |the |stoma |to |
minimize |irritation |of |the |skin |from |exposure |to |urine.
A |nurse |is |providing |teaching |to |a |client |who |has |hypothyroidism |and |is |receiving |
levothyroxine. |The |nurse |should |instruct |the |client |that |which |of |the |following |supplements |
can |interfere |with |the |effectiveness |of |the |medication? |- | |correct |answers |Calcium
,Calcium |limits |the |development |of |osteoporosis |in |clients |who |are |postmenopausal |and |works
|as |an |antacid. |Calcium |supplements |can |interfere |with |the |metabolism |of |a |number |of |
medications, |including |levothyroxine. |The |nurse |should |instruct |the |client |to |avoid |taking |
calcium |within |4 |hr |of |levothyroxine |administration.
A |nurse |is |conducting |an |admission |history |for |a |client |who |is |to |undergo |a |CT |scan |with |an |IV
|contrast |agent. |The |nurse |should |identify |that |which |of |the |following |findings |requires |further
|assessment? |- | |correct |answers |History |of |asthma |
A |client |who |has |a |history |of |asthma |has |a |greater |risk |of |reacting |to |the |contrast |dye |used |
during |the |procedure. |Other |conditions |that |can |result |in |a |reaction |to |contrast |media |include |
allergies |to |foods, |such |as |shellfish, |eggs, |milk, |and |chocolate.
A |nurse |in |an |ICU |is |assessing |a |client |who |has |a |traumatic |brain |injury. |Which |of |the |following
|findings |should |the |nurse |identify |as |a |component |of |Cushing's |triad? |- | |correct |answers |
Bradycardia |
A |client |who |has |increased |intracranial |pressure |from |a |traumatic |brain |injury |can |develop |
bradycardia, |which |is |one |component |of |Cushing's |triad. |The |other |components |of |Cushing's |
triad |are |severe |hypertension |and |a |widened |pulse |pressure.
A |nurse |is |planning |to |irrigate |and |dress |a |clean, |granulating |wound |for |a |client |who |has |a |
pressure |injury. |Which |of |the |following |actions |should |the |nurse |take? |- | |correct |answers |Use |
a |30-mL |syringe |
The |nurse |should |use |a |30-mL |to |60-mL |syringe |with |an |18- |or |19- |gauge |catheter |to |deliver |
the |ideal |pressure |of |8 |pounds |per |square |inch |(psi) |when |irrigating |a |wound. |To |maintain |
healthy |granulation |tissue, |the |wound |irrigation |should |be |delivered |at |between |4 |and |15 |psi.
,A |nurse |in |an |emergency |department |is |reviewing |the |provider's |prescriptions |for |a |client |who
|sustained |a |rattlesnake |bite |to |the |lower |leg. |Which |of |the |following |prescriptions |should |the |
expect? |- | |correct |answers |Administer |an |opioid |analgesic |to |the |client. |
The |nurse |should |expect |a |prescription |for |an |opioid |analgesic |to |promote |comfort |following |a
|rattlesnake |bite.
A |nurse |is |reviewing |the |health |record |of |a |client |who |is |scheduled |for |allergy |skin |testing. |The
|nurse |should |postpone |the |testing |and |report |to |the |provider |which |of |the |following |findings?
|(Click |on |the |"Exhibit" |button |for |additional |information |about |the |client). |- | |correct |answers |
Current |medications |
The |nurse |should |review |the |client's |medication |record |and |identify |medications, |including |
ACE |inhibitors, |beta |blockers, |theophylline, |nifedipine, |and |glucocorticoids, |such |as |
prednisone, |that |can |alter |the |allergy |skin |test |results. |These |medications |can |diminish |the |
client's |reaction |to |the |allergens. |The |nurse |should |notify |the |provider |and |instruct |the |client |
to |discontinue |prednisone |for |2 |weeks |before |allergy |skin |testing.
A |nurse |is |a |caring |for |a |client |who |is |on |bed |rest |and |has |a |new |prescription |for |enoxaparin |
subcutaneous. |Which |of |the |following |actions |should |the |nurse |take? |- | |correct |answers |Inject |
the |medication |into |the |anterolateral |abdominal |wall. |
The |nurse |should |inject |the |medication |into |the |anterolateral |or |posterolateral |abdominal |wall
|to |enhance |medication |absorption |and |prevent |hematoma |formation.
A |nurse |is |caring |for |a |client |who |has |a |stage |III |pressure |injury. |Which |if |the |following |findings
|contribute |to |delayed |wound |healing? |- | |correct |answers |Urine |output |25 |mL/hr |
Urinary |output |reflects |fluid |status. |Inadequate |urine |output |can |indicate |dehydration, |which |
can |delay |wound |healing.
, A |nurse |is |caring |for |a |client |who |has |a |new |prescription |for |total |parenteral |nutrition |(TPN). |
The |client |is |to |receive |2,000 |kcal |per |day. |The |TPN |solution |has |500kcal/L. |The |IV |pump |
should |be |set |at |how |many |mL/hr? |(Rounding |to |the |nearest |whole |number.) |- | |correct |
answers |167 |mL/hr
A |nurse |is |teaching |a |client |who |has |a |family |history |of |colorectal |cancer. |To |help |mitigate |this |
risk, |which |of |the |following |dietary |alterations |should |the |nurse |recommend? |- | |correct |
answers |Add |cabbage |to |the |diet. |
To |help |reduce |the |risk |for |colorectal |cancer, |the |client |should |consume |a |diet |that |is |high |in |
fiber, |low |in |fat, |and |low |in |refined |carbohydrates. |Brassica |vegetables |such |as |cabbage, |
cauliflower, |and |broccoli, |are |high |in |fiber.
A |nurse |is |caring |for |a |client |who |has |a |prescription |for |silver |sulfadiazine |cream |to |be |applied
|to |her |burn |wounds. |The |nurse |should |evaluate |the |client |for |which |of |the |following |
laboratory |findings? |- | |correct |answers |Leukopenia |
Transient |leukopenia |is |an |adverse |effect |of |silver |sulfadiazine.
A |nurse |is |teaching |a |client |with |systemic |erythematosus |who |has |a |new |prescription |for |
prednisone. |The |nurse |should |instruct |the |client |to |monitor |for |which |of |the |following |adverse
|effects |of |this |medication? |- | |correct |answers |Infection |
The |nurse |should |instruct |the |client |to |avoid |contact |with |people |who |are |ill |and |monitor |for |
manifestations |of |an |infection |such |as |a |fever |or |a |sore |throat. |Prednisone |can |suppress |the |
client's |immune |response |and |mask |the |manifestations |of |an |infection.
A |nurse |is |providing |preoperative |teaching |to |a |client |who |will |undergo |a |total |laryngectomy. |
Which |of |the |following |statements |indicates |that |the |client |understands |the |impact |of |the |
surgery? |- | |correct |answers |"I |understand |that |I |will |have |a |permanent |tracheostomy |after |the |
surgery." |
