ATI MED SURG EXAM – 73 QUESTIONS AND ANSWERS
A newly admitted client tells the nurse he is allergic to latex. Describe three (3) actions the nurse can do to assure the client's safety regarding latex products during the client's hospitalization. Correct Ans ➡ 1. Schedule sx in morning
2. Have latex free cart available
3. Make sure allergy is noted in the chart
A nurse is caring for a client with skeletal traction following a fracture. How and when should skeletal pin care be provided? Correct Ans ➡ Frequently throughout immobilization per hospital policy (at least 3x day), you want to observe pin sites for drainage, loosening of pins and
tenting of skin, make sure to not remove crusting at pin site , provide pain/muscle relaxants PRN
A nurse is providing community teaching regarding prevention of HIV transmission. Identify two (2) points the nurse will share with the client. Correct Ans ➡ - Using latex condoms to
prevent transmission
- Taking prescribed medication to reduce risk of transmission
Describe three (3) teaching points the nurse would provide to a client and their family regarding the treatment and transmission of tuberculosis. Correct Ans ➡ -Medications must be taken for 6 to 12 months, compliance is very important
- Sputum samples are needed every 2 to 4 weeks to monitor therapy effectiveness
During d/c teaching a client inquires further about airborne precautions and implementation of airborne precautions at home with a nurse. How should the nurse respond to the inquiry of precautions in the home setting? Correct Ans ➡ Proper hand hygiene ,Dispose of contaminated tissues in plastic bag, cover mouth and nose when coughing/sneezing
A nurse is caring for an adult male client following a lumbar spinal surgery. Which of the following findings would indicate a fluid volume deficit? Correct Ans ➡ -BUN 30 mg/dL
A nurse is teaching a client about risk factors associated with breast cancer. Provide three (3) risk
factors the nurse should discuss with the client. Correct Ans ➡ - Menopausal Hormonal therapy (HT)
- Hx of family breast cancer
- Nulliparity
List three (3) teaching points the nurse can provide a client with cholelithiasis on dietary choices for symptom management. Correct Ans ➡ -Consume low-fat diet rich in HDL (seafood, nuts, olive oil)
- Do not smoke
-Exercise regularly
The nurse is assessing a client with peripheral vascular disease. Describe the clinical manifestations the nurse would anticipate for venous insufficiency versus arterial insufficiency. Correct Ans ➡ - PAD : Decreased or absent peripheral pulses, Capillary refill > 3 sec, loss of hair in legs/feet, cool temperature gradient down the leg
- vI: Capillary refill <3sec, bronze brownish skin pigmentation, warm skin temperature
squamous cell carcinoma Correct Ans ➡ rough, scal lesion w/central ulceration + crusting
basal cell carcinomaterma Correct Ans ➡ Small, waxy nodule w/superficial blood vessels + well defined borders
malignant melanoma Correct Ans ➡ itching, cracks, ulcerations/ bleeding
Caring for client w/NG tube, nursing actions: Correct Ans ➡ maintain intermittent suction
asses patency and placement, irrigate q4hr
monitor/assess gastric output
monitor nasal area for skin breakdown
provide oral hygiene q2 hr
monitor VS, skin integ, I&O
What should you teach a patient about bronchoscopy? Correct Ans ➡ once gag reflex returns pt can have liquids/food
Post-op care for laminectomy Correct Ans ➡ turn the body as unit ( log roll)
back orthotic can be req 4- weeks after surg
following d/c initiate exercise plan
do not place overhead trapeze in bed
**monitor for clear halo-like drainage, sudden headache**
d/c teaching after Loop Electrosurgical Excision Procedure (LEEP) Correct Ans ➡ temp discomfort + cramping is expected
abstain from sexual intercourse and avoid douche/tampons, vag cream until disch stops (2weeks)
do not lift heavy objects for 2 weeks
Vancomycin AE ( rapid infusion) Correct Ans ➡ red man syndrome: rashes, itching, flushing, tachycardia and hypotension
Meds that interact w/warfarin include: Correct Ans ➡ acetaminophen, glucocorticoids, and
aspirin
Propanolol contraindications Correct Ans ➡ avoid use in:
- asthma
- diabetes
- CHF
- bradycardia
Blood type compatibility Correct Ans ➡ O- is universal donor
A newly admitted client tells the nurse he is allergic to latex. Describe three (3) actions the nurse can do to assure the client's safety regarding latex products during the client's hospitalization. Correct Ans ➡ 1. Schedule sx in morning
2. Have latex free cart available
3. Make sure allergy is noted in the chart
A nurse is caring for a client with skeletal traction following a fracture. How and when should skeletal pin care be provided? Correct Ans ➡ Frequently throughout immobilization per hospital policy (at least 3x day), you want to observe pin sites for drainage, loosening of pins and
tenting of skin, make sure to not remove crusting at pin site , provide pain/muscle relaxants PRN
A nurse is providing community teaching regarding prevention of HIV transmission. Identify two (2) points the nurse will share with the client. Correct Ans ➡ - Using latex condoms to
prevent transmission
- Taking prescribed medication to reduce risk of transmission
Describe three (3) teaching points the nurse would provide to a client and their family regarding the treatment and transmission of tuberculosis. Correct Ans ➡ -Medications must be taken for 6 to 12 months, compliance is very important
- Sputum samples are needed every 2 to 4 weeks to monitor therapy effectiveness
During d/c teaching a client inquires further about airborne precautions and implementation of airborne precautions at home with a nurse. How should the nurse respond to the inquiry of precautions in the home setting? Correct Ans ➡ Proper hand hygiene ,Dispose of contaminated tissues in plastic bag, cover mouth and nose when coughing/sneezing
A nurse is caring for an adult male client following a lumbar spinal surgery. Which of the following findings would indicate a fluid volume deficit? Correct Ans ➡ -BUN 30 mg/dL
A nurse is teaching a client about risk factors associated with breast cancer. Provide three (3) risk
factors the nurse should discuss with the client. Correct Ans ➡ - Menopausal Hormonal therapy (HT)
- Hx of family breast cancer
- Nulliparity
List three (3) teaching points the nurse can provide a client with cholelithiasis on dietary choices for symptom management. Correct Ans ➡ -Consume low-fat diet rich in HDL (seafood, nuts, olive oil)
- Do not smoke
-Exercise regularly
The nurse is assessing a client with peripheral vascular disease. Describe the clinical manifestations the nurse would anticipate for venous insufficiency versus arterial insufficiency. Correct Ans ➡ - PAD : Decreased or absent peripheral pulses, Capillary refill > 3 sec, loss of hair in legs/feet, cool temperature gradient down the leg
- vI: Capillary refill <3sec, bronze brownish skin pigmentation, warm skin temperature
squamous cell carcinoma Correct Ans ➡ rough, scal lesion w/central ulceration + crusting
basal cell carcinomaterma Correct Ans ➡ Small, waxy nodule w/superficial blood vessels + well defined borders
malignant melanoma Correct Ans ➡ itching, cracks, ulcerations/ bleeding
Caring for client w/NG tube, nursing actions: Correct Ans ➡ maintain intermittent suction
asses patency and placement, irrigate q4hr
monitor/assess gastric output
monitor nasal area for skin breakdown
provide oral hygiene q2 hr
monitor VS, skin integ, I&O
What should you teach a patient about bronchoscopy? Correct Ans ➡ once gag reflex returns pt can have liquids/food
Post-op care for laminectomy Correct Ans ➡ turn the body as unit ( log roll)
back orthotic can be req 4- weeks after surg
following d/c initiate exercise plan
do not place overhead trapeze in bed
**monitor for clear halo-like drainage, sudden headache**
d/c teaching after Loop Electrosurgical Excision Procedure (LEEP) Correct Ans ➡ temp discomfort + cramping is expected
abstain from sexual intercourse and avoid douche/tampons, vag cream until disch stops (2weeks)
do not lift heavy objects for 2 weeks
Vancomycin AE ( rapid infusion) Correct Ans ➡ red man syndrome: rashes, itching, flushing, tachycardia and hypotension
Meds that interact w/warfarin include: Correct Ans ➡ acetaminophen, glucocorticoids, and
aspirin
Propanolol contraindications Correct Ans ➡ avoid use in:
- asthma
- diabetes
- CHF
- bradycardia
Blood type compatibility Correct Ans ➡ O- is universal donor
