ATI MED SURG Proctored Exam (2)

1. A nurse is assessing a client who has right-sided heart failure. Which of the followings should the nurse expect to find? a. Poor skin turgor b. Pitting edema c. S3/S4 galloping heart-sounds d. Oliguria 2. A nurse is contacting the provider of a client who has cancer and is expecting breakthrough pain. Which of the following prescriptions should the nurse anticipate? a. Intramuscular meperidine b. Transmucosal fentanyl c. Intravenous dexamethasone d. Oral acetaminophen 3. A nurse is caring for an older adult client who is 72hr postoperative following a total hip arthroplasty. The client requires a PRN medication prior to ambulation. Which of the following medications should the nurse anticipate administering? a. Meperidine b. Naproxen c. Oxycodone d. Indomethacin 4. A nurse is providing teaching for a client who has diabetes mellitus about the self-administration of insulin. The client has prescriptions for regular and NPH insulins. Which of the following statements by the client indicates and understanding of the teaching? a. I will draw up the regular insulin into the syringe first b. I will store prefilled syringes in the refrigerator with the needle pointed downward c. I will shake the NPH vial vigorously before drawing up the insulin d. I will insert the needle at a 15-degree angle 5. A nurse is caring for a client who has admitted with nausea, vomiting, and a possible bowel obstruction. An NG tube is placed and set to low intermittent suction. Which of the following findings should the nurse report to the provider? a. The client reports being extremely thirsty with a sore throat b. The amount of drainage is gradually decreasing c. The client’s abdomen becomes distended and firm d. The drainage is bright green in color with brown fecal material 6. A nurse on a medical unit is planning care for a group of clients. Which of the following clients should the nurse attend to first a. A client who has multiple sclerosis and reports ataxia and vertigo b. A client who has thrombocytopenia and reports a nosebleed c. A client who has chronic obstruction pulmonary disease and an oxygen saturation of 89% d. A client who has left-sided paralysis and slurred speech from a prior stroke 7. A nurse is assessing a client who is receiving magnesium sulfate IV for the treatment of hypomagnesemia. Which of the following findings indicates effectiveness of the medications? a. Hyperactive bowel sounds b. Blood pressure 90/50 mm hg c. Lung clear d. Apical pulse 82/min 8. A nurse is caring for a client who has advanced liver disease. Which of the following laboratory results should the nurse monitor when assessing the client? a. Serum ammonia b. Glucose level c. Phosphate level d. Serum troponin 9. A nurse is providing instructions about foot care for a client who has peripheral arterial disease. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching? a. I apply a lubricating lotion to the cracked areas on the sole of my feet every morning b. I rest in my recliner with my feet elevated for about an hour every afternoon c. I soak my feet in hot water before trimming my toenails d. I use my heating pad on a low setting to keep my feet warm 10. A nurse is providing teaching to a client who has a DVT. Which of the following findings should the nurse identify as a risk factor for the development of the DVT a. NSAIDs use b. Oral contraceptive use c. HTN d. Cirrhosis 11. A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse? a. Check potassium levels b. Administer 0.9% sodium chloride c. Begin bicarbonate continuous IV infusion d. Initiate a continuous IV insulin infusion 12. A nurse is caring for a client who takes Lisinopril for HTN. Which of the following client statements indicates an adverse effect of the medication? a. I have a heightened sense of taste b. I have a nagging, dry cough c. I have to urinate frequently d. I seem to be bruising more easily 13. A nurse is caring for a client who is receiving TPN. Which of the following nursing actions are appropriate? (select all that apply) a. Infuse 0.9% sodium chloride if the solution is not available b. Increase the rate of infusion if administration is delayed c. Monitor serum blood glucose drug infusion d. Verify the solution with another RN prior to infusion e. Obtain the client’s weight daily 14. A home care nurse is planning to use nonpharmacological pain relief measures for an adult client who has severe chronic back pain. Which of the following guidelines should the nurse use? a. D/C opioids before trying nonpharmacological methods of pain relief b. Use imagery with client who have difficulty with focus and concentration c. Pain relief from the use of heat and cold continues for several hours after removal of the stimulus d. Distraction changes the client’s perception of pain, but doesn’t affect the cause 15. A nurse is caring for a client who has an endotracheal tube. Which of the following actions should the nurse take to verify tube placement? a. Deflate the cuff to check the tube placement b. Place the client’s head and neck in a flexed position c. Observe for symmetry of chest expansion d. Document the tube length where it passes the chin 16. A nurse is assessing for positive Chvostek’s sign following a thyroidectomy. Which of the following areas on the client’s head should the nurse tap to assess the client for tetany? a. Front of the ear 17. A nurse is caring for a client who has diabetes insipidus. Which of the following medications should the nurse plan to administer? a. Desmopressin b. Lithium carbonate c. Regular insulin d. Furosemide 18. A nurse is caring for a client who has flail chest. Which of the following actions should the nurse take? a. Implement fluid restriction b. Administer acetaminophen orally c. Provide humidified oxygen d. Administer antibiotic medication 19. A nurse is providing discharge teaching to a client who has chronic urinary tract infections. The client has a prescription for ciprofloxacin 250mg PO twice daily. Which of the following instructions should the nurse include in the teaching? a. Take a laxative to prevent constipations b. Take an antacid 30min before taking the medication c. Monitor heart rate once daily d. Drink 2 to 3 L of fluid daily 20. A nurse is completing an assessment of an older adult client and notes reddened areas over the bony prominence, but the client’s skin is intact. Which of the following interventions should the nurse include in the plan of care a. Apply an occlusive dressing b. Turn and reposition the client every 4hr c. Support bony prominences with pillows d. Massage the reddened areas three times daily 21. A nurse is preparing a client for a lumbar puncture. Which of the following images indicates the position the nurse should assist the client into for this procedure a. Laying on the side with the knee close to the chest 22. A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of the following findings should the nurse expect? a. BUN 15mg/dL b. Elevated BP c. Urine specific gravity 1.001 d. Hypothermia 23. A nurse working in the emergency department is caring for a client who has a burn injury. After securing the client’s airway, which of the following interventions should the nurse take first? a. Start an IV with a large-bore needle b. Administer analgesic medication c. Cleanse the client’s wounds d. Increase the room temperature 24. A nurse is providing discharge teaching for a client who has HIV. Which of the following information is the priority for the nurse to review with the client? a. List some ways you can cope with the stress of your illness b. Name a few things you will change about your diet c. Tell me why it’s important to have your CD4+ count checked d. Described your daily medication schedule 25. A nurse is caring for a client who is taking furosemide. The client has potassium level of 3.1 which of the following should the nurse assess first? a. Level of orientation b. Urine output c. Muscle weakness d. Cardiovascular status 26. A nurse is planning care for a client who is experiencing seizures secondary to meningitis. Which of the following interventions should the nurse include in the plan of care? (select all that apply) a. Dim the overhead lights b. Apply a warming blanket c. Have suction equipment at the bedside d. Assist the client to ambulate every 4 hr e. Place a tongue blade at the bedside 27. A nurse is caring for a client who has systemic lupus erythematosus. During assessment, which of the following should the nurse expect to find? a. Esophagitis b. Joint inflammation c. “bull’s eye” lesion d. Tophi 28. A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)? a. Deviation of the tongue from midline b. Inability to smell c. Loss of peripheral vision d. Disequilibrium with movement 29. A nurse is providing discharge teaching to a client who has a permanent pacemaker. Which of the following statements by the client indicated an understanding of the teaching? a. When a microwave oven is in use, I need to stay out of the room b. The pacemaker will deliver a shock if I develop a dysrhythmia c. I need to check my pulse rate every day for a full minute d. I need to maintain pressure over the pacemaker site with an elastic bandage 30. A nurse is admitting a client who reports chest pain and has been replaced on a telemetry monitor. Which of the following should the nurse analyze to determine whether the client is experiencing a MI? a. QRS duration b. ST segment c. PR interval d. T wave 31. A nurse is teaching a group of newly licensed nurse about acute respiratory failure. Which of the following manifestation should the nurse include in the teaching? a. Hypocarbia b. Hypoxemia c. Hypervolemia d. Hyperventilation 32. A nurse is caring for a client who as a central venous access device and notes the tubing has become disconnected. The client develops dyspnea and tachycardia. Which of the following actions should the nurse take first? a. Clamp the catheter b. Obtain ABG values c. Perform an ECG d. Turn the client to his left side 33. A nurse is preparing to administer a medication for a client through a nontunneled percutaneous central catheter. Which of the following actions should the nurse take? a. Apply a local anesthetic to the skin b. Close the inline clamp c. Flush the catheter with 10ml of 0.9% sodium chloride d. Don sterile gloves 34. A nurse is caring for an older adult client who has not been eating. Which of the following findings indicates dehydration? a. Crackles auscultated bilaterally b. Capillary refill of 2sec c. Engorged neck veins d. Diminished peripheral pulses 35. A nurse is providing teaching to a client who is postoperative following a partial glossectomy. Which of the following statements by the client indicates an understanding of the teaching? a. I will inspect my mouth once each week for sores b. I will consume canned soup whenever sores appear in my mouth c. I will rinse my toothbrush with hydrogen peroxide and water after each use d. I will drink orange juice to increase my vitamin C intake 36. A nurse is performing an ear irrigation for a client. Which of the following actions should the nurse take? a. Insert the tip of the syringe 2.5cm (1in) into the ear canal b. Tilt the client’s head 45 c. Use cool fluid for irrigation d. Point the tip of the syringe toward the top of the ear canal 37. A nurse is preparing to administer daily medications to a client who is undergoing a procedure at 1000 that requires IV contrast dye. Which of the following routine medications to give at 0800 should the nurse withhold? a. Valproic acid b. Metformin c. Metoprolol d. Fluticasone 38. A nurse in an emergency department is assessing a client who has cirrhosis of the liver. Which of the following is a priority finding? a. Mental confusion b. Palmar erythema c. Spider angiomas d. Yellow sclera 39. A nurse is assessing a client who has acute kidney failure. Which of the following findings should the nurse report to the provider? a. Urine specific gravity 1.045 b. Creatinine 0.8ml/dl c. Weight gain 1.1kg (2.4lb) in 24hr d. Peripheral pulses 2+ bilaterally 40. A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The client reports sharp lower abdominal pain. Which of the following actions should the nurse take first? a. Increase the client’s fluid intake b. Reposition the client in bed c. Check the client’s urine output d. Administer PRN pain medication