ATI PN Adult Medical Surgical 2020 with NGN

A nurse is caring for a client who is taking lithium and reports persistent nausea and vomiting for 2 days. Which of the following laboratory values should the nurse report to the provider? a) Potassium 4.0 mEq/L b) Lithium 0.9 mEq/L c) BUN 12 mg/dL d) Sodium 132 mEq/L - D. Sodium 132 mEq/L A nurse is caring for a client who has cancer and has a WBC count of 4,000/mm3. Which of the following actions should the nurse take? a) Cleanse the client's toothbrush with hydrogen peroxide. b) Instruct the client to use a disposable razor to shave. c) Decrease the client's protein intake. d) Encourage the client to eat unpasteurized dairy products. - A. Cleanse the client's toothbrush with hydrogen peroxide. A nurse enters a client's room and sees smoke coming from the bathroom. Which of the following actions should the nurse take first? a) Activate the fire alarm system. b) Use a fire extinguisher at the source of the smoke. c) Assist the client to a nearby common area. d) Close the doors to the room and to the bathroom. - C. Assist the client to a nearby common area. A nurse is contributing to the plan of care for a client who reports difficulty eating due to chronic arthritis. Which of the following interventions should the nurse include in the plan? a) Apply foam handles to the client's eating utensils. b) Obtain a referral for physical therapy. c) Have an assistive personnel feed the client. d) Ask the provider for a prescription for a pureed diet. - A. Apply foam handles to the client's eating utensils. A nurse is obtaining a medication history from a client who is to start taking nitroglycerin for chest discomfort with activity. Which of the following medications should the nurse instruct the client to avoid taking within 24 hr of using nitroglycerin? a) Atorvastatin b) Metformin c) Sildenafil d) Omeprazole - C. Sildenafil A nurse is preparing to obtain a postprandial blood glucose level from a client who has diabetes mellitus. Which of the following actions should the nurse take? a) Apply the first drop of blood to the test strip. b) Clean the client's finger with hexachlorophene. c) Prick the central tip of the client's finger. d) Hold the client's finger in a dependent position. - D. Hold the client's finger in a dependent position. A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching? a) "It is common for one breast to be larger than the other." b) "It is common for the skin on my breasts to dimple." c) "I will perform breast exams the day my period begins." d) "I will perform breast exams every other month." - A. "It is common for one breast to be larger than the other." A nurse is reinforcing teaching with a client who has a new ileostomy. Which of the following statements by the client indicates an understanding of the teaching? a) "I will need to empty the bag every 4 to 6 hours." b) "I will use moisturizing soap to clean around the stoma before applying the bag." c) "I will use a skin sealant before I apply the bag." d) "I will cut the wafer opening one-fourth of an inch larger than the stoma." - C. "I will use a skin sealant before I apply the bag." A nurse is assisting in the plan of care for a client who is dehydrated and is receiving IV fluid replacement. Which of the following interventions should the nurse contribute to the plan of care? a) Offer oral fluids every 4 hr. b) Check for neck vein distention. c) Limit oral fluids prior to bedtime. d) Monitor pulse pressure every 6 hr. - B. Check for neck vein distention. A nurse is caring for a young adult client who has testicular cancer and expresses concern about their sexual function following an orchiectomy of the involved testicle. Which of the following responses should the nurse make? a) "I'm sure any partner will understand that you have no control over this." b) "There are other ways to express intimacy besides intercourse." c) "You should focus on recovering from your cancer right now." d) "The removal of a single testicle will not prevent you from having an erection." - D. "The removal of a single testicle will not prevent you from having an erection." A nurse is collecting data from a client who has hyperthyroidism and is taking propylthiouracil. Which of the following statements by the client indicates the medication is effective? a) "I no longer feel nervous." b) "I no longer take a stool softener." c) "I have less oily skin." d) "I continue to lose weight." - A. "I no longer feel nervous." A nurse is planning care for a client who is receiving radiation therapy to treat throat cancer and reports a change in the taste of food. Which of the following interventions should the nurse include in the plan of care? a) Offer artificial saliva frequently. b) Add honey to sweeten fruit smoothies. c) Heat food before serving. d) Provide three large meals daily. - C. Heat food before serving. A nurse working the night shift is caring for an older adult client who has dementia and is at risk for falls. Which of the following actions should the nurse take? a) Raise all four side rails while the client is in bed. b) Apply a motion sensor mat to the client's bed. c) Leave the television on in the client's room. d) Move the overbed table away from the bed. - B. Apply a motion sensor mat to the client's bed. A nurse is reinforcing teaching with a client about increasing her intake of fiber. Which of the following foods should the nurse encourage the client to eat? a) Cheese b) Pears c) Yogurt d) Eggs - B. Pears A nurse is reviewing the medical record of a client who reports his urine is redorange. The nurse should identify which of the following medications can cause this adverse effect? a) Isoniazid b) Metoprolol c) Furosemide d) Rifampin - D. Rifampin A nurse is caring for a client in hospice care who is dying. The client's partner expresses concern that the client is sleeping more than in the previous week. Which of the following is an appropriate response by the nurse? a) "Encourage your partner to wake up to interact with family members." b) "Sitting quietly near the bedside can provide comfort and support." c) "I will call the provider to discuss your concerns." d) "I can ask the provider to prescribe a medication that will minimize drowsiness." - B. "Sitting quietly near the bedside can provide comfort and support." A nurse is reinforcing teaching with a client who is postoperative following a tympanoplasty. Which of the following information should the nurse include? a) Drink fluids through a straw. b) Plan to shampoo hair in 1 week. c) Resume exercising in 10 days. d) Close mouth when sneezing. - B. Plan to shampoo hair in 1 week. A nurse is reinforcing discharge teaching about dietary changes with a client who has a new colostomy. Which of the following foods should the nurse recommend? a) Asparagus b) Bananas c) Grapes d) Broccoli - B. Bananas A nurse is caring for a client who has diabetes mellitus. Which of the following laboratory results should the nurse report to the provider? a) Glycosylated hemoglobin 5.2% b) Urine positive for ketones c) Urine negative for bilirubin d) Fasting blood glucose 70 mg/dL - b. Urine positive for ketones A nurse is caring for an older adult client who has heart failure. Which of the following findings should the nurse report to the provider? a) Urinary output of 1,000 mL in 12 hr b) Potassium level 4.5 mEq/L c) PaCO2 55 mm Hg d) Chest x-ray showing cardiomegaly - C. PaCO2 55 mm Hg A nurse is caring for a client who has diabetic neuropathy of the lower extremities and has a new prescription for a heating pad. The prescription reads, "Apply to the left food for 20 min." Which of the following actions should the nurse take? a) Complete Semmes-Weinstein monofilament testing following treatment. b) Apply the heating pad as prescribed by the provider. c) Clarify the prescription with the provider. d) Observe the skin 10 min after the start of treatment. - C. Clarify the prescription with the provider A nurse is reinforcing teaching with a client who has a new colostomy. Which of the following statements by the client indicates an understanding of the teaching? a) "I should clean around the stoma with moisturizing soap." b) "I should avoid broccoli and chewing gum." c) "I should decrease the amount of fresh fruit in my diet." d) "I should place an aspirin in the pouch to eliminate odor." - B. "I should avoid broccoli and chewing gum." A nurse is collecting data from a client who has a newly placed colostomy. Which of the following findings should indicate to the nurse the client has accepted their new altered body image? a) Denies feelings of sadness about the ostomy b) Prefers not to look at the stoma site c) Accepts that seual activity will decrease d) Participates in performing ostomy care - D. Participates in performing ostomy care A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider? a) Ammonia 55 mcg/dL b) Bilirubin 1.0 mg/dL c) Platelets 60,000/mm3 d) Aspartate aminotransferase 34 units/L - C. Platelets 60,000/mm3 A nurse is assisting with the plan of care for a client who requires contact precautions. Which of the following interventions should the nurse include in the plan? a) Keep a stethoscope at the client's bedside for the duration of her hospital stay. b) Wear an N95 mask when entering the room. c) Use an alcohol swab to clean the temperature probe before removing it from the room. d) Remove personal protective equipment immediately after leaving the client's room. - A. Keep a stethoscope at the client's bedside for the duration of her hospital stay. A nurse is caring for a client who has a prescription for propranolol for the treatment of atrial fibrillation. Which of the following actions should the nurse take? a) Request a dosage increase of the apical heart rate is less than 60/min. b) Administer the medication with an antacid. c) Instruct the client to expect increased hair growth. d) Withhold the medication if the systolic blood pressure is less than 90 mm Hg. - D. Withhold the medication if the systolic blood pressure is less than 90 mm Hg. A nurse is reinforcing teaching about dietary modifications to help control blood pressure with a client who has hypertension. Which of the following food choices by the client indicates an understanding of the teaching? a) A ham sandwich on rye bread b) Broiled cod with broccoli c) Beef bouillon with crackers d) Pork sausage with sauteed peppers - B. Broiled cod with broccoli A nurse is reinforcing teaching with a client about heart disease prevention, which of the following client statements indicates an understanding of the teaching? a) "I will increase my dairy intake by drinking whole milk every meal." b) "I will exercise by walking twice a week for 25 minutes." c) "I will try to maintain my blood pressure around 116/72." d) "I will improve my LDL cholesterol by raising it from 100 to 130." - C. "I will try to maintain my blood pressure around 116/72." A nurse is reinforcing teaching about a transcutaneous electrical nerve stimulation (TENS) unit for a client who has a herniated intervertebral disk. Which of the following statements by the client indicates an understanding of the teaching? a) "I will need to charge the TENS unit for 2 hours each day." b) "The TENS unit administers a continuous dose of pain medication." c) "I should adjust the TENS unit until I feel a tingling sensation." d) "The TENS unit should be applied at least 6 inched from the actual site of my pain." - C. "I should adjust the TENS unit until I feel a tingling sensation. A nurse is reviewing a client's medical record. Which of the following findings is the priority for the nurse to report? a) Urine output 200 mL/8 hr b) A client's rating of ear pain as 5 on a scale from 0 to 10 c) Potassium level 6.2 mEq/L d) Abnormal hepatoiminodiacetic acid (HIDA) scan - C. Potassium level 6.2 mEq/L A nurse is reinforcing teaching about decreasing the risk of osteoporosis to a client who is postmenopausal. Which of the following instructions should the nurse include? a) Limit vitamin D intake. b) Increase daily intake of vitamin E. c) Add a weight-bearing exercise regimen. d) Take calcium carbonate supplements once a day with breakfast. - C. Add a weight-bearing exercise regimen. A nurse is caring for a client who has COPD with copious secretions. Which of the following actions should the nurse take? a) Place the client in prone position. b) Administer high-flow oxygen. c) Limit fluid intake. d) Perform postural drainage. - D. Perform postural drainage. A nurse is collecting data from a client who had a long arm cast applied 2 hr ago. Which of the following findings of the affected extremity should the nurse report to the provider immediately? a) The client reports increased pain at the area of the fracture. b) The client reports severe itching under the cast. c) The client's capillary refill is 3 seconds. d) The client's fingers are cool to the touch. - D. The client's fingers are cool to the touch. A nurse is reinforcing teaching with a client who has diabetes melitus about reducing the risk for a stroke. Which of the following statements by the client indicates an understanding of the teaching? a) "Having a total cholesterol level below 200 mg/dL increases my risk for a stroke." b) "My provider might prescribe a glucocorticoid regimen to decrease my risk for a stroke." c) "My risk for a stroke increases if my HbA1c level is 6 percent or less." d) "I can decrease my risk for a stroke by losing excess weight." - D. "I can decrease my risk for a stroke by losing excess weight." A nurse is monitoring a client who has a nasogastric (NG) tube set to intermittent suction to manage a mechanical intestinal obstruction. Which of the following findings should the nurse report? a) Potassium 4.2 mEq/L b) BUN 16 mg/dL c) Abdominal distention d) Bile-colored drainage from the NG tube - C. Abdominal distention A nurse working in a provider's office is caring for a client who received penicillin 6 potassium 15 min ago to treat strep throat. Which of the following is the priority finding the nurse should report to the provider? a) Nausea b) Hypotension c) Abdominal pain d) Arthralgia - C. Abdominal pain A nurse is collecting data from a client who began taking captopril 2 days ago. Which of the following findings should the nurse report to the provider immediately? a) Lip swelling b) Dizziness c) Joint aches d) Metallic taste - A. Lip swelling A nurse is caring for a client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take when assisting the client with feeding? a) Offer the client sticky foods such as peanut butter. b) Instruct the client to place their chin to their chest when swallowing. c) Place food on the affected side of the client's mouth. d) Position the client upright for 5 min after eating. - B. Instruct the client to place their chin to their chest when swallowing. A nurse is reinforcing teaching with a client who has ovarian cancer and will receive chemotherapy through a peripherally inserted central catheter (PICC) line. Which of the following statements by the client indicates an understanding of the teaching? a) "I will wear an arm immobilizer to prevent dislodgement of this device." b) "I will monitor my temperature for fever while I have this device." c) "It's okay to get the device wet when I shower." d) "I should pull the dressing away from the insertion site when I change it." - B. "I will monitor my temperature for fever while I have this device." A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take? a) Replace the unit when the drainage chamber is full. b) Clamp the tube for 30 min every 8 hr. c) Pin the tubing to the client's bed sheets. d) Monitor for at least 150 mL of drainage every hour. - D. Monitor for at least 150 mL of drainage every hour. A nurse is collecting data from a client who is 2 days postoperative following a colon restriction. Which of the following indicates the need for nursing intervention? a) Mild abdominal pain when coughing 30 min after receiving pain medication b) Dark brown drainage in the NG tube c) Serosanguineous drainage on the wounddressing d) Oxygen saturation 95% - B. Dark brown drainage in the NG tube A nurse is caring for a client who is visually impaired. When delivering the client's meal tray, which of the following actions should the nurse take? a) Provide the client with a small-handled adaptive utensil. b) Arrange for an assistive personnel to feed the client. c) Describe the food placement as though the plate were a clock. d) Discourage conversations during the client's mealtime. - C. Describe the food placement as though the plate were a clock. A nurse is reinforcing teaching with a client who is starting to take metformin extended release. Which of the following instructions should the nurse include in the instructions? a) Monitor blood glucose while taking this medication. b) Chew the medication before swallowing. c) Expect muscle pain while taking this medication. d) Take the medication with breakfast. - A. Monitor blood glucose while taking this medication. A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care? a) Advise the client about increased dry mouth. b) Check the client for increased hypopigmentation under the patch. c) Monitor the client for weight loss. d) Inform the client of the adverse effect of diarrhea. - B. Check the client for increased hypopigmentation under the patch. A nurse is receiving a change-of-shift report about the care of four clients. Which of the following clients should the nurse see first? a) A client who displays increased confusion over the past 4 hr b) A client who has a blood glucose level of 128 mg/dL c) A client who has a blood pressure of 138/88 mm Hg d) A client who reports a pain level of 4 on a scale of 0 to 10 - A. A client who displays increased confusion over the past 4 hr A nurse is assisting care of a client whose cardiac monitor suddenly displays ventricular tachycardia. Which of the following is the priority nursing action? a) Determine palpable pulse. b) Begin chest compressions. c) Perform immediate defibrillation. d) Provide pulmonary ventilation. - A. Determine palpable pulse. A nurse is collecting data from a client who underwent a thyroidectomy 4 hr ago. Which of the following client findings indicates a complication of the procedure? a) Tingling of the fingers b) Report of sore throat c) Serosanguineous drainage on the dressing d) Soreness at the incision site - A. Tingling of the fingers A nurse is reinforcing discharge teaching with a client who had an excisional biopsy of the left breast. Which of the following instructions should the nurse include? a) Refrain from wearing a bra for 10 days after surgery. b) Apply an ice pack to the incision site to treat discomfort. c) Expect numbness to last for up to 4 months. d) Use bandages to absorb bleeding at the incision site. - B. Apply an ice pack to the incision site to treat discomfort. A nurse is collecting data from a client who has peritonitis. Which of the following findings should the nurse expect? a) Peripheral edema b) Decreased respirations c) Absent bowel sounds d) Polyuria - C. Absent bowel sounds A nurse is reinforcing teaching with a client about menopause. Which of the following statements by the client indicates an understanding of the teaching? a) "I will need hormone replacement therapy for the rest of my life." b) "I should expect to have an increased risk for breast cancer." c) "The use of black cohosh will decrease vaginal bleeding." d) "I should use a vaginal douche to prevent dryness." - B. "I should expect to have an increased risk for breast cancer." A nurse is reinforcing teaching with a client who has gastroesophageal reflux disease. Which of the following dietary instructions should the nurse include? a) Chew food thoroughly. b) Use a straw when drinking liquids. c) Drink carbonated beverages with meals. d) Limit meals to three per day with no snacking in between. - A. Chew food thoroughly A nurse is preparing a client for a colposcopy following an abnormal Papanicolaous (Pap) test. Which of the following actions should the nurse take? a) Place the client in the Sims' position. b) Reinforce teaching that the procedure involves dilation of the cervix. c) Insert a tampon following the procedure. d) Instruct the client to avid sexual intercourse until the cervix is healed. - D. Instruct the client to avid sexual intercourse until the cervix is healed. A nurse is assisting with the development of the plan of care for a client who has a low WBC count. Which of the following interventions should the nurse include? a) Encourage the client to eat a low-protein diet. b) Prohibit fresh flowers in the client's room. c) Obtain the client's rectal temperature every 4 hr. d) Initiate airborne precautions for the client. - B. Prohibit fresh flowers in the client's room. A nurse is reinforcing teaching with a female client who has a history of urinary tract infections. Which of the following instructions should the nurse include? a) Use a vaginal douche once a week. b) Empty the bladder at least every 6 hr. c) Increase milk consumption to make the urine more alkaline. d) Urinate before and after sexual intercourse. - D. Urinate before and after sexual intercourse.