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ATI MEDSURG COMPREHENSIVE REVIEW
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– HIGH-YIELD CONCEPTS, CRITICAL CARE # # #
FOCUS & PROCTORED EXAM MASTERY # # # #
GUIDE
An older adult is brought to an emergency department by a family member.
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Which of the following assessment findings should cause the nurse to suspect
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that the client has hypertonic dehydration? - -- ANSWER>>>>--Urine Specific
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gravity 1.045 #
A urine specific gravity greater than 1.030 indicates a decrease in urine volume
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and an increase in osmolarity, which is a manifestation of hypertonic dehydration.
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A nurse in a community clinic is caring for a client who reports an increase in the
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frequency of migraine headaches. To help reduce the risk for migraine headaches,
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which of the following foods should the nurse recommend the client avoid? - --
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ANSWER>>>>--Aged cheese #
Foods that contain tyramine, such as aged cheese and sausage, can trigger
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migraine headaches. #
A nurse is planning teaching for a client who has bladder cancer and is to undergo
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a cutaneous diversion procedure to establish a ureterostomy. Which of the
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following statements should the nurse include in the teaching? - --
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,#
ANSWER>>>>--"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
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stoma to minimize irritation of the skin from exposure to urine.
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A nurse is providing teaching to a client who has hypothyroidism and is receiving
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levothyroxine. The nurse should instruct the client that which of the following
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supplements can interfere with the effectiveness of the medication? - --
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ANSWER>>>>--Calcium
Calcium limits the development of osteoporosis in clients who are
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postmenopausal and works as an antacid. Calcium supplements can interfere with
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the metabolism of a number of medications, including levothyroxine. The nurse
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should instruct the client to avoid taking calcium within 4 hr of levothyroxine
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administration.
A nurse is conducting an admission history for a client who is to undergo a CT scan
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with an IV contrast agent. The nurse should identify that which of the following
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findings requires further assessment? - -- ANSWER>>>>--History of asthma
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A client who has a history of asthma has a greater risk of reacting to the contrast
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dye used during the procedure. Other conditions that can result in a reaction to
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contrast media include allergies to foods, such as shellfish, eggs, milk, and
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chocolate.
A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of
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the following findings should the nurse identify as a component of Cushing's
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triad? - -- ANSWER>>>>--Bradycardia
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,#
A client who has increased intracranial pressure from a traumatic brain injury can
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develop bradycardia, which is one component of Cushing's triad. The other
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components of Cushing's triad are severe hypertension and a widened pulse
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pressure.
A nurse is planning to irrigate and dress a clean, granulating wound for a client
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who has a pressure injury. Which of the following actions should the nurse take? -
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-- ANSWER>>>>--Use a 30-mL syringe
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The nurse should use a 30-mL to 60-mL syringe with an 18- or 19- gauge catheter
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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.
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A nurse in an emergency department is reviewing the provider's prescriptions for
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a client who sustained a rattlesnake bite to the lower leg. Which of the following
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prescriptions should the expect? - -- ANSWER>>>>--Administer an opioid
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analgesic to the client. # # #
The nurse should expect a prescription for an opioid analgesic to promote
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comfort following a rattlesnake bite.
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A nurse is reviewing the health record of a client who is scheduled for allergy skin
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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). - -- ANSWER>>>>--Current medications
# # # # # #
,#
The nurse should review the client's medication record and identify medications,
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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
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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? -
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-- ANSWER>>>>--Inject the medication into the anterolateral abdominal wall.
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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? - -- ANSWER>>>>--
# # # # # # # # #
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.) - -- ANSWER>>>>--167 mL/hr
# # # # # #
ATI MEDSURG COMPREHENSIVE REVIEW
# # #
– HIGH-YIELD CONCEPTS, CRITICAL CARE # # #
FOCUS & PROCTORED EXAM MASTERY # # # #
GUIDE
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? - -- ANSWER>>>>--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? - --
# # # # # # # # # # # # #
ANSWER>>>>--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? - --
# # # # # # # # # #
,#
ANSWER>>>>--"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? - --
# # # # # # # # # #
ANSWER>>>>--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? - -- ANSWER>>>>--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? - -- ANSWER>>>>--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? -
# # # # # # # # # # # # # #
-- ANSWER>>>>--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? - -- ANSWER>>>>--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). - -- ANSWER>>>>--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? -
# # # # # # # # # # #
-- ANSWER>>>>--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? - -- ANSWER>>>>--
# # # # # # # # #
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.) - -- ANSWER>>>>--167 mL/hr
# # # # # #
