ATI Med Surg Proctored Exam Practice Questions and Complete Solutions.

ATI Med Surg Proctored Exam Practice Questions and Complete Solutions A nurse is caring for a client who had a left lower lobectomy to treat lung cancer. Which of the following factors will have a significant impact on the plan of care for this client? - Ans: C. Lung cancer usually has metastasized before the client presents with symptoms. A nurse is preparing a plan of care for a client who is postoperative following a modified radical mastectomy. Which of the following invasive devices should the nurse expect this client to have? - Ans: D. Jackson-Pratt drain A nurse is monitoring a client who has heart failure related to mitral stenosis. The client reports shortness of breath on exertion. Which of the following conditions should the nurse expect? - Ans: D. Increased pulmonary congestion A nurse is caring for a client who is postoperative following a total knee arthroplasty and has been prescribed a continuous passive motion (CPM) machine and PCA. The client tells the nurse, "I am in so much pain." Which of the following actions should the nurse take first? - Ans: C. Ask the client to describe the characteristics of the pain A nurse is reviewing the laboratory results of a lumbar puncture (LP) for a client who has manifestations of bacterial meningitis. Which of the following findings should the nurse expect? - Ans: B. Elevated protein A nurse is admitting a client who has manifestations that suggest tuberculosis. Which of the following actions is the nurse's priority? - Ans: A. Initiate airborne precautions A nurse is providing information to a client who is scheduled for an exercise electrocardiography test. Which of the following client statements indicates an understanding of the teaching? - Ans: A. "I will not drink coffee 4 hours prior to my test." A nurse is assessing a client who has osteoarthritis. The client's medical record indicates the presence of Heberden's nodes. Which of the following findings should the nurse expect? - Ans: D. Hard lumps over the joints of the fingers A nurse is caring for a client who has a fractured hip and was placed in Buck's traction 4 hours ago. Which of the following actions should the nurse take? - Ans: B. Encourage the client to perform dorsiflexion of the affected extremity every 2 hours A nurse is auscultating the lungs of a client who is having an acute asthma attack. Which of the following sounds should the nurse expect to hear? - Ans: D. Noisy wheezing A nurse is providing discharge teaching to the partner of a client who has acquired immune deficiency syndrome (AIDS). Which of the following statements by the client's partner indicates a need for further teaching? - Ans: B."I'll clean up blood spills immediately with hot water." A nurse is preparing an in-service presentation about the basics of hematology. Which of the following factors provides a stimulus for the production of RBCs? - Ans: D. Tissue hypoxia A nurse is admitting a client who is in sickle cell crisis. Besides pain management, which of the following interventions should the nurse include in the client's plan of care? - Ans: D. Ample hydration A nurse is assessing a client who has Addison's disease. Which of the following findings should the nurse expect? - Ans: A. Hypotension A nurse is teaching a client who has chronic kidney disease (CKD). Which of the following instructions should the nurse include? - Ans: A. Limit fluid intake A nurse is teaching a group of clients about the functions of the liver and gallbladder. Which of the following should the nurse include in the teaching as the purpose of bile? - Ans: A. Digesting fats A nurse is assessing an older adult client for physiological changes that can occur with age. Which of the following findings should the nurse expect? - Ans: B. Decreased sense of taste A nurse is caring for a client with Addison's disease who has been admitted with muscle weakness, dehydration, and nausea and vomiting for the past 2 days. Which of the following prescribed medications should the nurse plan to administer? - Ans: C. Hydrocortisone A nurse is developing a plan of care for a client who as gastroesophageal refulx disease (GERD). The nurse should plan to monitor the client for which of the following complications? - Ans: A. Aspiration A female client who has recurrent cystitis asks the nurse about preventing future episodes. For which of the following client statements should the nurse provide future teaching? - Ans: B. "I prefer taking tub baths to showering." A nurse is assessing the abdominal incision of a client who is 3 days postoperative. The incision is slightly edematous and pink with crusting on the edges and is draining serosanguineous fluid. Which of the following assessments describes the incision? - Ans: C. The incision is showing signs of healing without complications A nurse is assisting a provider with performing a paracentesis on a client. Which of the following actions should the nurse take? - Ans: A. Ask the client to empty his bladder before the procedure A nurse is examining the ECG of a client who has frequent premature ventricular contractions (PVCs). Which of the following QRS changes should the nurse expect to see on the client's ECG? - Ans: B. Much greater amplitude than the usual QRS complexes A nurse is teaching a group of clients about skin cancer. The nurse should explain that basal cell carcinoma originates from which of the following tissues? - Ans: B. Epidermis A nurse is admitting a client who has cirrhosis. Which of the following prescriptions should the nurse anticipate? (Select all that apply) - Ans: A. Obtain the client's PT and INR measurements B. Administer lactulose 30 mL PO 4 times daily C. Obtain daily weights and abdominal girth measurements D. Administer a daily multivitamin A nurse is caring for a client who is concerned about the possibility of contracting Lyme disease after receiving a tick bite. For which of the following early manifestations of Lyme disease should the nurse assess the client? - Ans: D. Progressive circular rash A nurse is monitoring a newly licensed nurse who is caring for a client. The client has active pulmonary tuberculosis, was placed on airborne precautions, and is scheduled for a chest X-ray. The nurse should instruct the newly licensed nurse to take which of the following actions? - Ans: A. Have the client wear a surgical mask A home health nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following foods should the nurse include in the client's plan of care? - Ans: D. Baked chicken A nurse on a surgical unit is caring for 4 clients who have healing wounds. Which of the following wounds should the nurse expect to heal by primary intention? - Ans: C. Surgical incision A nurse is caring for a client who is 3 days postoperative following a right total hip arthroplasty. While transferring to a chair, the client cries out in pain. The nurse should assess the client for which of the following manifestations of dislocation of the hip prosthesis? - Ans: B. Shortening of the right leg Which of the following findings is the highest risk factor for the client developing skin cancer? - Ans: Overexposure to sunlight Assessing Client who has cataracts. Which of the following should the nurse expect? - Ans: Opacity visible behind the pupil The release of histamine causes which of the following reactions? - Ans: Increased mucus secretion Which of the following findings is an indication of the prodromal stage of inhalation anthrax? - Ans: Dry cough Which of the following pieces of information in the client's medical record should the nurse identify as a risk factor for tinnitus? - Ans: Sclerosis of the ossicles Internal radiation therapy for the treatment of cervical cancer. For which of the following actions by the newly licensed nurse should the charge nurse intervene? - Ans: Borrowing a dosimeter film badge from another nurse before entering the client's room Herpes zoster. The nurse should anticipate a prescription for which of the following medications? - Ans: Acyclovir Allergy to dust. The nurse should determine that the client understands how to reduce her exposure to this allergen through which of the following statements? - Ans: "I will put a mattress cover on my bed." Polycythemia vera about self-care measures. Which of the following interventions should the nurse include? - Ans: "Elevate your legs when sitting." Discharge teaching to a client who has aplastic anemia. Which of the following statements indicates that the client understands the instructions? - Ans: "I should eliminate uncooked foods from my diet for now." Preparing a client for an electromyogram (EMG). Which of the following statements indicates that the client understands the pre-procedure teaching? - Ans: "This test will help my doctor know if my nerves are working correctly." Which of the following findings is the highest risk factor for the client developing bladder cancer? - Ans: The client uses tobacco Which of the following findings should the nurse recognize as an indication of a tension pneumothorax? (Select all that apply) - Ans: Tracheal deviation to the left Absent breath sounds on the right side Neck vein distention Thick urethral discharge. Which of the following actions should the nurse take? - Ans: Obtain a urethral specimen for culture Receptive aphasia. Which of the following communication problems should the nurse expect when assessing the client? - Ans: The client is unable to understand words or sentences she hears Addisonian crisis and has a blood pressure of 74/42 mmHg. Which of the following prescriptions should the nurse anticipate? - Ans: Hydrocortisone Right-sided heart failure. Which of the following findings should the nurse expect? - Ans: Dependent edema Below-the-knee amputation. Which of the following pieces of information should the nurse include in the teaching? - Ans: Instruct the client to lie prone while in bed Somogyi effect and takes intermittent-acting insulin. Which of the following actions should the nurse include in the plan? - Ans: Monitor the client's nighttime blood glucose levels Diabetic neuropathy. Which of the following statements by the client demonstrates an understanding of the teaching? - Ans: "I will wash my feet daily and apply lotion, except between my toes." The nurse should monitor for and report which of the following findings as an indication of compartment syndrome? - Ans: Paresthesias of the extremity Low-cholesterol diet to a client who had a myocardial infarction. Which of the following meal selections by the client indicates an understanding of the teaching? - Ans: Chicken breast and corn on the cob Full-thickness burns covering 63% of her body and smoke inhalation. Which of the following nursing actions is the top priority? - Ans: Monitor respiratory status Client who has fruity breath odor, a dry mouth, and extreme thirst. Which of the following assessments should the nurse make? - Ans: Blood glucose level The nurse notes that the client's dialysis output is less than the input and that his abdomen is distended. Which of the following actions should the nurse take? - Ans: Change the client's position Indwelling urinary catheter. Which of the following actions should the nurse take? - Ans: Empty the drainage bag when half-full of urine Which of the following findings should the nurse identify as a risk factor for coronary artery disease? (Select all that apply) - Ans: Hypertension Diabetes mellitus Hyperlipidemia Tobacco smoking Dumping syndrome following gastric bypass surgery 4 days ago. Which of the following recommendations should the nurse include in the teaching? - Ans: Maintain a supine position after meals 1 week postoperative following a total knee replacement. Which of the following statements by the client indicates an understanding of the teaching? - Ans: "I plan to use a walker to help me get around." Which of the following findings is a clinical manifestation of acute respiratory distress syndrome (ARDS)? - Ans: PaO2 50 mmHg Which of the following clients is at risk for iron deficiency? (Select all that apply) - Ans: A client who is a vegetarian A client who is pregnant A toddler who is overweight 72 hours postoperative following an above-the-knee amputation. Which of the following actions should the nurse take? - Ans: Assist the client into a prone position every 4 hours Magnetic imaging resonance (MRI) examination of the cervical vertebrae. Which of the following pieces of information in the client's history is a contraindication to this procedure? - Ans: The client has a pacemaker Rewarming a client following a coronary artery bypass graft (CABG) surgery. For which of the following complications of the rewarming process should the nurse monitor the client? - Ans: Acidosis Metabolic alkolosis. Which of the following laboratory values should the nurse expect? - Ans: pH 7.49; HCO3 32 mEq/L; PACO2 40 mmHg Function of cranial nerve X. Which of the following assessment procedures should the nurse use? - Ans: Have the client open his mouth and say, "ahh" Which of the following types of fractures is especially common in children? - Ans: Greenstick Which of the following precautions should the nurse offer to minimize the adverse effects of thrombocytopenia? - Ans: Remind the client to use an electric razor Brachytherapy to treat uterine cancer. The nurse should ensure the client understands that she will receive which of the following interventions? - Ans: Radioactive infusions or insertions into or near the tumor Which of the following factors increase the client's risk of developing breast cancer? - Ans: Age over 50 years Continuous tube feeding through a pump at 75mL/hr. When the nurse assesses the client at 0800, which of the following findings requires intervention? - Ans: The head of the bed is elevated to 20 degrees Which of the following findings should the nurse identify as an indication of an acute intravascular hemolytic reaction? - Ans: Sudden oliguria Immediately following extubation. Which of the following manifestations indicates that the nurse should call the rapid response team? - Ans: Stridor Postoperative following a conventional lumbar disk excision. Which of the following statements indicates that the client understands the nurse's instructions? - Ans: "I'll use my heating pad if I feel any muscle spasms in my back." Possible cardiac tamponade. In what order should the nurse complete the following steps? - Ans: 1) Palpate the blood pressure and inflate the cuff.... 2)Deflate the cuff slowly and listen.... 3)Identify the first BP sounds..... 4)Subtract the inspiratory pressure..... 5)Inspect for JVD..... Preoperative for a cystoscopy. Which of the following statements should the nurse make? - Ans: "Expect to have pink-tinged urine after this procedure." The nurse notes absent breath sounds on the client's left side and a tracheal shift to the right. For which of the following procedures should the nurse prepare the client? - Ans: Chest tube insertion Depressed skull fracture of the bone that makes up the larger part of the upper and side wall of the cranium. This fracture is located on which of the following bones? - Ans: Parietal Intravenous pyelogram (IVP). Which of the following findings should the nurse report to the provider? - Ans: Vomiting and diarrhea for the last 6 hr Dumping syndrome. Which of the following instructions should the nurse include? - Ans: Eat a source of protein with each meal Fluid volume overload from a cardiovascular disorder. Which of the following manifestations should the nurse expect? (Select all that apply) - Ans: Jugular vein distention Moist crackles Increased heart rate Resucscitation phase following a major burn. Which of the following laboratory findings should the nurse expect? - Ans: Sodium 132 mEq/L The nurse should explain to the client that which of the following is the main function of the gallbladder? - Ans: Storing bile Peritoneal dialysis. The nurse should monitor the client for which of the following adverse effects? - Ans: Peritonitis Atherosclerosis. Which of the following laboratory findings should the nurse identify as an increased risk for this disorder? - Ans: Elevated LDL levels Sickle cell anemia and a history of receiving blood transfusions. For which of the following complications should the nurse monitor? - Ans: Iron toxicity Foot care for a client who has diabetes mellitus. Which of the following instructions should the nurse include? - Ans: Test water temperature with the wrist Preoperative prior to a transurethral resection of the prostate (TURP). Which of the following client statements indicates an understanding of the information? - Ans: "I will feel the urge to urinate following this procedure." Interventions to reduce pain at the onset of a migraine. Which of the following instructions should the nurse include in the teaching? - Ans: "Darken the lights." COPD. Which of the following manifestations should the nurse identify as an indication of impending respiratory failure? - Ans: Tachycardia Chronic pancreatitis. Which of the following food items should the nurse suggest removing from the client's menu for the following day? - Ans: Ice cream Extensive burns, including on her face. Which of the following assessments should the nurse perform first? - Ans: Characteristics of the cough and sputum Grave's disease. Which of the following findings should the nurse expect the client to display? - Ans: Difficulty sleeping Electroencephalogram (EEG). When the client asks the nurse what this test does, which of the following responses should the nurse provide. - Ans: An EEG records the electrical activity of your brain cells Encephalitis due to West Nile Virus. Which of the following actions should the nurse take? (Select all that apply) - Ans: Monitor vital signs every 2 hours Assess neurological status every 4 hours Keep the client's room darkened Food choices to a client who has diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? - Ans: "I should replace white bread with whole-grain bread." Hepatic encephalopathy. The nurse should anticipate a prescription for which of the following laboratory tests to determine the possibility of recent excessive alcohol use? - Ans: Gamma-gutamyl transferase (GGT) Cisplatin IV. The nurse should identify that which of the following findings is an adverse effect of this medication? - Ans: Tinnitus Which of the following findings is an early manifestation of ALS? - Ans: Weakness of the distal extremities Type 2 diabetes mellitus. The client states, "I eat pasta everyday. I can't imagine giving it up." Which of the following responses should the nurse provide? - Ans: "You don't have to give up pasta; just adjust the amount you eat." Type 1 diabetes mellitus and a capillary blood glucose reading of 48 mg/mL. Which of the following findings should the nurse expect? - Ans: Diaphoresis Sickle cell crisis. Which of the following statements indicates that the client understands the instructions? - Ans: "Physical activity is good for me, but I need to avoid overexertion." Assessed a client's airway, breathing, and circulation (ABC) following a head injury at work. Which of the following actions is the priority for the nurse to perform next? - Ans: Immobilize the client's cervical spine New diagnosis of hepatitis A. Which of the following instructions should the nurse include in the teaching? - Ans: "Encourage her to eat foods that are high in carbohydrates." A client who has Alzheimer's disease. The child is the client's sole caregiver and reports feeling fatigued and overwhelmed. Which of the following referrals should the nurse make for the caregiver? - Ans: Respite care Acute myelogenous leukemia and a platelet count of 48,000/mm^3. Which of the following interventions should the nurse include? - Ans: Avoid IM injections Laboratory results of a client who has diabetes mellitus. Which of the following results indicates that the client's diabetes is controlled? - Ans: Fasting blood glucose 95 mg/dL Brachytherapy in an ambulatory care clinic. Which of the following statements by the client indicates an understanding of the teaching? - Ans: "I need to lie still in bed during my brachytherapy treatment." Urolithiasis and reports pain in his thigh. This finding indicates the stone is in which of the following structures? - Ans: Ureter Current recommendations for early detection of breast cancer. The nurse should explain which of the following options? - Ans: Begin annual mammograms at age 40 Client who has Addison's disease. Which of the following skin manifestation should the nurse expect to find? - Ans: Bronze pigmentation of the skin Client who has a brain tumor for computed tomography (CT). Which of the following factors affects the manner in which the nurse will prepare the client for the scan? - Ans: Development of hives when eating shrimp Pursed-lip breathing for a client who has chronic obstructive pulmonary disease (COPD) with emphysema. This breathing technique accomplishes which of the following? - Ans: Promotes carbon dioxide elimination Which of the following is a manifestation of bladder trauma? - Ans: Hematuria Recurrent external otitis. Which of the following instructions should the nurse include in the teaching? - Ans: Instill a diluted alcohol solution into the ear after swimming Client who has chronic obstructive pulmonary disease (COPD) and is experiencing shortness of breath. Which of the following actions should the nurse perform first? - Ans: Place the client in the upright position The client asks how to prevent future uric acid stones. Which of the following suggestions should the nurse provide? (Select all that apply) - Ans: Take allopurinol as prescribed Exercise several times a week Limit intake of foods high in purine Laboratory values of a client who has chronic kidney disease. The nurse should expect elevations in which of the following values? - Ans: Potassium and magnesium Tuberculin skin test. Which of the following pieces of information should the nurse include? - Ans: "You must return to the clinic to have the test read in 2 or 3 days." Discharge following a bronchoscopy. Which of the following assessments is the nurse's monitoring priority? - Ans: Confirming the gag reflex Client who has emphysema. Which of the following instructions should the nurse include? - Ans: "Try to drink at least 2 to 3 liters of fluid per day." The nurse should report which of the following findings to the provider as a possible indication of a hematologic disorder? - Ans: Absence of hair on the legs Kaposi's sarcoma. Which of the following findings should the nurse expect? - Ans: Reddish-purple skin lesions Hip arthroplasty. The nurse places an abduction pillow on the client for which of the following purposes? - Ans: To prevent dislocation of the hip during position changes or movement Type 2 diabetes mellitus about foot care. Which of the following statements by the client indicates an understanding of the teaching? - Ans: "I'll be sure to wear cotton socks everyday." Which of the following enzymes plays a role in the digestion of protein? - Ans: Pepsin Reducing the risk of cervical cancer. Which of the following interventions should the nurse include? - Ans: Get the human papillomavirus (HPV) immunization Heterograft dressing. In response to the client's questions about the dressing, the nurse explains that it is obtained from which of the following sources? - Ans: Pig skin 48 hr postoperative following open reduction and internal fixation of a fractured tibia. Which of the following findings should the nurse report to the provider? - Ans: Toes that are cold to the touch Which of the following types of isolation should the nurse implement to prevent the transmission of HIV? - Ans: Standard precautions 4 days postoperative following the creation of a colostomy and refuses to look at the stoma. Which of the following actions should the nurse take? - Ans: Postpone any teaching with the client at this time Type 1 diabetes mellitus. Which of the following statements should the nurse include? - Ans: "Wear a medical alert identification tag when you exercise." Which of the following blood vessels carry deoxygenated blood to the right atrium? - Ans: Superior vena cava Acute pancreatitis. Which of the following serum laboratory values should return to the expected reference range within 72 hr of treatment beginning? - Ans: Amylase Packed red blood cells (RBCs) for a client who has anemia. Which of the following actions should the nurse take first? - Ans: Witness the informed consent document Liver biopsy for a suspected malignancy. Which of the following laboratory findings should the nurse monitor prior to the procedure? - Ans: Prothrombin time Primary open-angle glaucoma (POAG). Which of the following pieces of information should the nurse include in the teaching? (Select all that apply) - Ans: Driving can be dangerous..... Laser surgery can help reestablish.... Brachytherapy. Which of the following measures should the nurse include in the client's plan of care? - Ans: Keep the door to the client's room closed History of urinary tract infections (UTIs). Which of the following client statements indicates the need for additional teaching? - Ans: "I will use a vaginal douche daily." A client with arthritis that is experiencing joint pain that impairs mobility. Which of the following instructions should the nurse include? - Ans: "Apply heat to your joints prior to exercising." Early stages of hepatitis A. Which of the following manifestations should the nurse expect? - Ans: Anorexia Which of the following minerals should the nurse identify as involved in oxygen transportation? - Ans: Iron 2 days postoperative following gastric surgery and has an NG tube inserted. Which of the following findings should the nurse report to the provider? - Ans: 200 mL of bright red drainage from the NG tube Client who has a snakebite on her arm. Which of the following interventions should the nurse implement? - Ans: Immobilize the limb at the level of the heart The nurse should identify that hepatitis A is transmitted by which of the following routes? - Ans: Fecal-oral contamination Breathing techniques to a client who has emphysema. Which of the following statements indicates that the client understands the mechanics of pursed-lip breathing? - Ans: "When I breath out through pursed-lips, my airways don't collapse between breaths." Which of the following client manifestations is an expected finding of peripheral neuropathy? - Ans: Tingling of the hands and feet Removed the endotracheal tube. Which of the following actions should the nurse take first? - Ans: Evaluate the client for stridor Continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following findings should the nurse report to the provider? - Ans: Viscous urinary output with clots Fulminant hepatic failure. Which of the following procedure should the nurse anticipate for this client? - Ans: Liver transplant Client who has leukemia and has developed thrombocytopenia. Which of the following instructions should the nurse include in the teaching? - Ans: "Use an electric razor when shaving." Client who has pancreatitis. In which of the following laboratory results should the nurse expect to see an elevation? - Ans: Amylase Bone-marrow biopsy. Which of the following pieces of information should the nurse include in preoperative teaching? - Ans: "You'll feel a painful, pulling sensation when the doctor withdraws the marrow." Why platelets are so important. Which of the following responses should the nurse make? - Ans: "Platelets plug breaks in blood vessels." Client who has GERD. The nurse should expect the client to report which of the following manifestations? (Select all that apply) - Ans: Regurgitation Nausea Belching Heartburn Deep-vein thrombosis in her left calf. Which of the following manifestations should the nurse expect to find? (Select all that apply) - Ans: Hardening along the blood vessel Tenderness in the calf Increased leg circumference Complete intestinal obstruction. Which of the following findings should the nurse expect? - Ans: Hyperactive bowel sounds above the obstruction On entering, the nurse finds that the client has slid toward the foot of the bed, and the traction weight is resting on the floor. Which of the following actions should the nurse take? - Ans: Have the client use a trapeze to pull himself up..... Left-sided heart failure. Which of the following findings should the nurse expect? - Ans: Crackles in the lung bases Emphysema and chronic respiratory acidosis. The nurse should monitor the client for which of the following electrolyte imbalances? - Ans: Hyperkalemia Celiac disease. Which of the following foods should the nurse remove from the client's meal tray? - Ans: Wheat toast Osteomalacia. The nurse should identify that this condition is caused by a deficiency in which of the following nutrients? - Ans: Vitamin D Reducing the risk of osteoporosis. Which of the following pieces of information should the nurse include? - Ans: Walking is the preferred mode of exercise to maintain strong bones Client who has HIV. Which of the instructions about infection prevention should the nurse include? (Select all that apply) - Ans: Avoid large gatherings of people Clean toothbrush by running it through the dishwasher Avoid digging in the garden Electroencephalogram (EEG). Which of the following pieces of information should the nurse share with the client? - Ans: "You'll begin by lying still with your eyes closed." Treat bleeding esophageal varices. Which of the following pieces of information should the nurse include in the teaching? - Ans: The client will be placed on mechanical ventilation prior to this procedure Laser-assisted in situ keratomileusis (LASIK). Which of the following is an adverse effect of LASIK surgery? - Ans: Dry eyes Balanced skeletal traction to stabilize a femur fracture. Which of the following actions should the nurse include in the client's plan of care? - Ans: Offering the client a diet high in fluid and fiber The nurse should instruct the client's family to take which of the following actions first in the event of a seizure? - Ans: Protect the client's head Acute exacerbation of Crohn's disease. Which of the following actions should the nurse take? - Ans: Ensure bowel rest Which of the following disorders should the nurse identify as increasing the client's metabolic needs? (Select all that apply) - Ans: COPD Cancer Parkinson's Disease Major Burns Platelet count of 50,000/mm^3. After discontinuing the client's peripheral IV site, which of the following actions should the nurse take? - Ans: Apply pressure to the catheter removal site for 5 min Receiving chemotherapy and has developed neutropenia. Which of the following statements indicates that the client needs further instructions? - Ans: "I'm planning a large gathering of friends and family for the holidays." Deep partial-thickness and full-thickness thermal burns over 40% of his total body surface area and is in the acute phase of burn injury. Which of the following interventions should the nurse include in the plan? - Ans: Initiate range-of-motion exercises Exacerbation of herpes zoster. Which of the following manifestations of the client's skin should the nurse expect? - Ans: Unilateral, localized, nodular skin lesions Chronic pancreatitis. Which of the following findings should the nurse identify as a likely cause of the client's condition? - Ans: Alcohol use Which of the following findings indicates the client is experiencing increased intracranial pressure? - Ans: Dilated pupils Preoperative for a renal biopsy. Which of the following statements should the nurse make? - Ans: "You will need to be on bed rest following the procedure." The client will be discharged with 2 Jackson-Pratt drains. Which of the following pieces of information should the nurse include in the teaching? - Ans: "The drainage tubes often are removed at the same time as the stitches." Transient ischemic attack (TIA). Which of the following instructions should the nurse include? - Ans: Reduce dietary sodium Transient ischemic attack (TIA). Which of the following pieces of information should the nurse include in the teaching? - Ans: A TIA can preced an ischemic stroke Demand pacemaker inserted with a set rate of 72/min. Which of the following findings should the nurse expect? - Ans: Telemetry monitoring showing QRS compelxes occurring at a rate of 74/min with no pacing spikes Radiation therapy for mouth cancer and reports a dry mouth. Which of the following dietary recommendations should the nurse provide? - Ans: Use gravies or sauces to soften food When preparing the materials, the nurse should identify that which of the following groups is at risk for developing hepatitis A? - Ans: Children Client who has pyelonephritis about the disorder. Which of the following pieces of information should the nurse include to help the client prevent a recurrence? - Ans: "Wipe from front to back after defecation." Prostate-specific antigen (PSA) test. Which of the following directions should the nurse provide? - Ans: "You should not ejaculate for 24 hours prior to the PSA test." When a family member asks why the client has 2 chest tubes, which of the following responses should the nurse make? - Ans: "The lower tube will drain blood, and the higher tube will remove air." The nurse should identify the risk for a latex allergy when the client reports an allergy to which of the following foods? - Ans: Bananas Myasthenia gravis (MG). Which of the following pieces of information should the nurse include? - Ans: Set an alarm to ensure medication dosages are taken on time Thoracentesis. In which of the following positions should the nurse place the client? - Ans: Sitting while leaning forward over the bedside table Which of the following indicates the client is developing superior vene cava syndrome? - Ans: Facial edema Bleeding esophageal varices. The nurse should anticipate a prescription for which of the following medications? - Ans: Vasopressin Client who is on bed rest about preventing complications. Which of the following client statements indicates an understanding of the teaching? - Ans: "I should cough and deep-breathe every hour." Multiple myeloma and a white blood cell count of 2,200/mm^3. Which of the following foods should the nurse prohibit the family members from bringing to the client? - Ans: A fresh fruit basket Reviewing the medical record of client who has heart failure. Which of the following findings should the nurse expect? NOTE: A figure is present with this question - does not seem to have implications on answer. - Ans: BNP of 200 pg/mL Client who has heart failure and anticipates discharge to home the following day. Which of the following lunch choices should the nurse identify as an indication the client understands his dietary instructions? - Ans: Turkey on whole-wheat bread Sigmoid colon resection with colostomy. Which of the following statements by the client indicates a need for further teaching? - Ans: "I'll have to consume a soft diet after surgery." Radiation therapy for breast cancer and reports a metallic taste in the mouth. Which of the following dietary recommendations should the nurse share with the client? - Ans: Offer mints Ulcerative colitis. Which of the following food selections by the client indicates an understanding of the teaching? - Ans: Roast chicken and white rice Which of the following laboratory values should the nurse plan to obtain to assess for diabetes insipidus (DI)? - Ans: Specific gravity Chronic renal failure. Which of the following food choices by the client indicates an understanding of the teaching? - Ans: Grilled fish Newly placed ileostomy. Which of the following instructions should the nurse include in the teaching? - Ans: "Empty your ostomy pouch when it becomes half full." Dietary modifications for a client who has GERD. The nurse should suggest eliminating which of the following foods from the client's diet? - Ans: Oranges and tomatoes Total hip arthroplasty. Which of the following interventions should the nurse include in the plan? - Ans: Place a pillow between the client's legs The client is going home with an indwelling urinary catheter. Which of the following statements by the client indicates an understanding of the teaching? - Ans: "I will change the catheter drainage bag once each week." Diagnostic knee arthroscopy. Which of the following statements indicates that the client understands the nurse's instructions? - Ans: "I'll keep my leg elevated for the first day." Urinary diversion to treat bladder cancer. Which of the following interventions should the nurse include in the plan of care? - Ans: Change the collection pouch in the early morning Which of the following findings of peripheral vascular disease (PVD) is a risk factor of ulceration of the extremities? - Ans: Impaired circulation Which of the following findings should the nurse identify as an indication short-term memory impairment? - Ans: Inability to locate eyeglasses Lumbar disk excision. Which of the following interventions should the nurse include in the client's plan of care? - Ans: Logroll the client in bed for care procedures Autonomic dysreflexia due to a C5 spinal cord injury. After checking the client's vital signs, which of the following actions should the nurse perform next? - Ans: Place the client in a high-Fowler's position Coronary artery bypass grafts for cardiac tamponade. Which of the following actions should the nurse take? - Ans: Auscultate blood pressure for pulsus paradoxus Chest tube removed. Which of the following actions should the nurse take? - Ans: Instruct the client to perform the Valsalva maneuver during removal Presbyopia. With which of the following activities should the nurse expect the client to have difficulty? - Ans: Reading the newspaper Acute exacerbation of rheumatoid arthritis. The nurse should anticipate that the client's affected joints will require which of the following treatments? - Ans: Heat paraffin therapy applied to the client's joints Pernicious anemia. Which of the following findings should the nurse expect? - Ans: Paresthesias of the hands and feet Bilateral adrenalectomy. The nurse should expect to administer glucocorticoids following the procedure to enhance which of the following therapeutic effects? - Ans: Compensation for decreased cortisol levels ...."flash" of light followed by a "curtain" across the field of vision. The nurse should identify that these manifestations indicate which of the following eye disorders? - Ans: Retinal detachment Radioallergosorbent (RAST) testing due to seasonal allergies. The nurse should anticipate an elevation in which of the following immunoglobulin laboratory values? - Ans: IgE Total hip arthroplasty for discharge. Which of the following statements indicates that the client understands the instructions? - Ans: "I'll use a reacher to help me pick up anything I drop on the floor." Calcium oxalate renal calculi. Which of the following instructions should the nurse include? - Ans: "Consume 1,000 mg of dietary calcium daily." Chronic cough and is scheduled for a bronchoscopy. Which of the following client statements indicates an understanding of the teaching? - Ans: "A tissue sample might be obtained during the procedure." 4 hr postoperative following a laparoscopic cholecystectomy. Which of the following findings should the nurse expect? - Ans: Right shoulder pain Colostomy placement with a perineal wound. Which of the following statements by the client indicates an understanding of the teaching? - Ans: "I can only have liquids for 2 days before the surgery." Which of the following factors increases the risk for developing cancer after age 60? - Ans: Weakened immune response Protein-calorie malnutrition. Which of the following findings should the nurse expect? - Ans: Decreased albumin Which of the following statements indicates that the client understands how to care for the incision and his left upper leg? - Ans: "I will lie on my stomach for 30 min a few times a day.' The client appears alert and engaged during a visit but does not respond verbally to questions. The nurse should document this as which of the following alterations? - Ans: Expressive aphasia Cerebral lesion and develops hyperthermia. Which of the following areas of the client's brain is affected? - Ans: Hypothalamus Low-sodium diet to manage hypertension. Which of the following statements by the client indicates an understanding of the teaching? - Ans: "I can snack on fresh fruit." Reduce flatus and odor. Which of the following strategies should the nurse include? - Ans: Eat crackers and yogurt regularly 66-year-old client pneumococcal immunization. Which of the following responses should the nurse provide? - Ans: "Let's go ahead and give you this immunization." Meniere's disease. Which of the following instructions should the nurse include in the teaching? - Ans: Avoid sudden movements New colostomy. Which of the following actions should the nurse teach the client to perform? (Select all that apply) - Ans: Empty the bag when it is one-third to one-half full Cut the skin barrier opening a little larger than the ostomy Wash the peristomal skin with mild soap and water Partial gastrectomy. Which of the following instructions should the nurse include in the teaching? - Ans: "Eat protein with each meal." Transient ischemic attack (TIA) for discharge. The nurse should teach the client to monitor which of the following parameters at home? - Ans: Blood pressure Itching under the cast. Which of the following actions should the nurse plan to take? - Ans: Use a hair dryer on a cool setting to blow air into the cast Esophagogastroduodenoscopy (EGD). Which of the following statements should the nurse include in the teaching? - Ans: "This procedure can determine how well the lower part of your esophagus works." Stroke. Which of the following actions should the nurse take first? - Ans: Keep the client NPO Abdominal aortic aneurysm. Which of the following manifestations should the nurse expect? - Ans: Lower back discomfort The client has mild asthma, diabetes mellitus, and coronary artery disease. Which of the following statements by the client indicates an understanding of the teaching? - Ans: "My coronary artery disease is a risk factor for heart failure." Type 1 diabetes mellitus about hypoglycemia. Which of the following manifestations should the nurse include in the teaching? - Ans: Shakiness Pernicious anemia. The nurse should encourage the client to increase consumption of which of the following foods? - Ans: Eggs High-thoracic spinal cord injury. The nurse should identify which of the following as a manifestation of autonomic dysreflexia? - Ans: Report of a headache Scheduled for a total knee arthroplasty. Which of the following statements by the client indicates an understanding of the teaching? - Ans: "I should wear elastic stockings on both of my legs." Naproxen tablets. Which of the following statements by the client indicates a need for further teaching? - Ans: "I can take this medication with aspirin." Difference between colostomies and ileostomies. Which of the following responses should the nurse make? - Ans: "A colostomy is from the large intestine, and an ileostomy is from the small intestine." Alprazolam. Which of the following items is a priority for teaching? - Ans: "This medication can affect your ability to drive or handle mechanical equipment." Prescription for enoxaparin. Which of the following actions should the nurse take? - Ans: Elevate the affected leg Predialysis dietary recommendations. The nurse should recommend restricting the of which of the following nutrients? - Ans: Protein The child's parent ask the nurse about the role of the spleen in the body. The nurse should explain that the spleen performs which of the following functions? - Ans: Destroys old blood cells Breast self-examinations (BSE). The nurse should identify which of the following findings as an indication of breast cancer? - Ans: A nontender, hard lump that is palpated in a breast Impairment of cranial nerve II. Which of the following actions should the nurse perform to promote the client's safety? - Ans: Provide an obstacle-free path for ambulation Guaiac test from a client. This test is performed to detect which of the following? - Ans: Blood in stool Hodgkin's lymphoma. Which of the following findings should the nurse expect? - Ans: Enlarged lymph nodes Which of the following types of fractures results when a client's bone breaks into multiple pieces? - Ans: Comminuted The nurse should explain that alcohol can cause liver cirrhosis through which of the following actions? - Ans: Destroying liver cells that are later replaced with scar tissue Which of the following findings should alert the nurse to the possibility of malignant melanoma? - Ans: An irregularly shaped brown lesion with light blue areas on the neck Peritoneal dialysis. Which of the following findings should the nurse report to the provider immediately? - Ans: Cloudy effluent Odor of alcohol on their breath and multiple injuries to the head and extremities. Which of the following clients should the nurse assess first? - Ans: A client who is difficult to arouse and is unable to answer questions 3 objects for the client to remember. The nurse is using this strategy to test which type of memory? - Ans: Immediate Develops acute respiratory distress. Which of the following actions should the nurse take first? - Ans: Initiate bag-valve-mask ventilation Cast on his left arm to treat a fractured forearm. Which of the following statements indicates that the client understands the teaching? - Ans: "I'll call the doctor's office if my fingers get colder on the arm with the cast." Fresh frozen plasma (FFP). Which of the following laboratory results should the nurse review? - Ans: Prothrombin time Which of the following laboratory values is consistent with diabetic ketoacidosis? - Ans: Bicarbonate level 12 mEq/L What is the most common assessment finding with acute myocardial infarction (MI)? - Ans: Substernal chest pain Which of the following findings should the nurse identify as a manifestation of a myocardial infarction? - Ans: Acute confusion The client reports diarrhea, a dull headache, palpitations, and muscle tingling and weakness. Which of the following actions should the nurse take first? - Ans: Check the client's electrolyte values When teaching the client about skin cancer risk, which of the following risk factors should the nurse include? - Ans: Excessive exposure to ultraviolet light Hemophilia. The client reports pain and swelling in a joint following an injury. Which of the following actions should the nurse take? - Ans: Prepare for replacement of the missing clotting factor