Med surg- proctored ATI
A nurse in a clinic is assessing a client who was diagnosed with mononucleosis 2 weeks ago. Which of the following
findings should the nurse report to the provider immediately? - ANS -Abdominal pain in the left upper quadrant
When using the urgent vs non urgent approach to client care, the nurse should determine that the priority finding is left
upper-quadrant pain, which can indicate an enlarged spleen. An enlarged spleen can rupture, leading to internal
hemorrhaging. The nurse should encourage the client to refrain from engaging in strenuous activities until the
splenomegaly is resolved.
\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? -
ANS -Aged cheese
Foods that contain tyramine, such as aged cheese and sausage, can trigger migraine headaches.
\A nurse in a dermatology clinic is using the ABCDE method while screening several skin lesions for skin cancer on a
client. Which of the following findings should the nurse report to the provider? - ANS -Color variation within a lesion
The C in the ABCDE method of screening for skin cancer stands for color variation within a lesion. The E stands for
evolving or changing in any feature of the lesion.
\A nurse in a provider's office is assessing a client's skin lesion. The nurse notes that the lesions are 0.5 cm (0.20 in) in
size, elevated, and solid with distinct borders. The nurse should document these findings as which of the following skin
lesions? - ANS -Papules
A papule is a small, solid, elevated lesion with distinct borders. It is usually smaller than 10 mm in diameter. Papules are
common lesions of warts and elevated moles.
\A nurse in a provider's office is reviewing the medical records of a group of clients. 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
A client who is a vegetarian might require iron because the availability of iron in vegetable food sources is limited. During
pregnancy, maternal blood volume increases, and the fetus requires additional iron. Therefore, the RDA of iron for clients
who are pregnant is increased to 27 mg per day. Toddlers who are overweight may get most of their calories from milk
and foods that are not considered healthy, which increases their risk for iron-deficiency anemia.
\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? - ANS -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 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? - ANS -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 in the emergency department is assessing a client for closed pneumothorax and significant bruising of the left
chest following a motor-vehicle crash. The client reports severe left chest pain on inspiration. The nurse should assess the
client for which of the following manifestations of pneumothorax? - ANS -Absence of breath sounds
A client who has pneumothorax experiences severely diminished or absent breath sounds on the affected side.
\A nurse in the emergency department is assessing a client who was in a motor vehicle crash 2 days ago and sustained
fracture of his tibia, ulna, and several ribs. The client is not disoriented to time and place and has SaO2 of 87%. The nurse
notes generalized petechiae on the client's skin. Which of the following complications should the nurse suspect? - ANS
-Fat embolism syndrome
, The nurse should identify the triad of neurological changes, petechial rash, and hypoxemia as findings of fat embolism
syndrome. Risk factors include multiple fractures and a fracture of a long bone. Male clients are also at greater risk. The
manifestations occur when far globules occlude small blood vessels.
\A nurse in the emergency department is caring for a client who has Addison's disease and reports nausea, vomiting,
diarrhea, and abdominal pain. To prevent an Addisonian crisis, the nurse should prepare to administer which of the
following medications? - ANS -Hydrocortisone
Addison's disease causes adrenal gland hypofunction and inadequate production of glucocorticoids. Acute adrenal
insufficiency is life-threatening and can lead to severe fluid and electrolyte imbalances. Without treatment, sodium levels
fall, and potassium levels increase. Rapid infusion of IV fluids such as 0.9% sodium chloride and IV administer of high
dose corticosteroids such as hydrocortisone are vital to correct the glucocorticoid deficiency.
\A nurse in the PACU is assessing a newly admitted client and observes intercostal retractions and a high-pitched
inspiratory sound. The nurse should identify these findings as manifestations of which of the following complications? -
ANS -Respiratory obstruction
Intercostal retractions and a high-pitched inspiratory noise (i.e. stridor) are manifestations of an airway obstruction caused
by laryngospasm and edema. The nurse should notify the rapid response team and plan to administer racemic
epinephrine.
\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? - ANS -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 an acute care facility is preparing to admit a client who myasthenia gravis. Which of the following supplies
should the nurse place at the client's bedside? - ANS -Oral-nasal suction equipment
A client who has myasthenia gravis is at risk for aspiration due to progressive weakness of the oropharyngeal muscles.
Myasthenia gravis causes muscle weakness due to an autoimmune disease that affects the acetylcholine receptors. The
A nurse in a clinic is assessing a client who was diagnosed with mononucleosis 2 weeks ago. Which of the following
findings should the nurse report to the provider immediately? - ANS -Abdominal pain in the left upper quadrant
When using the urgent vs non urgent approach to client care, the nurse should determine that the priority finding is left
upper-quadrant pain, which can indicate an enlarged spleen. An enlarged spleen can rupture, leading to internal
hemorrhaging. The nurse should encourage the client to refrain from engaging in strenuous activities until the
splenomegaly is resolved.
\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? -
ANS -Aged cheese
Foods that contain tyramine, such as aged cheese and sausage, can trigger migraine headaches.
\A nurse in a dermatology clinic is using the ABCDE method while screening several skin lesions for skin cancer on a
client. Which of the following findings should the nurse report to the provider? - ANS -Color variation within a lesion
The C in the ABCDE method of screening for skin cancer stands for color variation within a lesion. The E stands for
evolving or changing in any feature of the lesion.
\A nurse in a provider's office is assessing a client's skin lesion. The nurse notes that the lesions are 0.5 cm (0.20 in) in
size, elevated, and solid with distinct borders. The nurse should document these findings as which of the following skin
lesions? - ANS -Papules
A papule is a small, solid, elevated lesion with distinct borders. It is usually smaller than 10 mm in diameter. Papules are
common lesions of warts and elevated moles.
\A nurse in a provider's office is reviewing the medical records of a group of clients. 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
A client who is a vegetarian might require iron because the availability of iron in vegetable food sources is limited. During
pregnancy, maternal blood volume increases, and the fetus requires additional iron. Therefore, the RDA of iron for clients
who are pregnant is increased to 27 mg per day. Toddlers who are overweight may get most of their calories from milk
and foods that are not considered healthy, which increases their risk for iron-deficiency anemia.
\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? - ANS -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 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? - ANS -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 in the emergency department is assessing a client for closed pneumothorax and significant bruising of the left
chest following a motor-vehicle crash. The client reports severe left chest pain on inspiration. The nurse should assess the
client for which of the following manifestations of pneumothorax? - ANS -Absence of breath sounds
A client who has pneumothorax experiences severely diminished or absent breath sounds on the affected side.
\A nurse in the emergency department is assessing a client who was in a motor vehicle crash 2 days ago and sustained
fracture of his tibia, ulna, and several ribs. The client is not disoriented to time and place and has SaO2 of 87%. The nurse
notes generalized petechiae on the client's skin. Which of the following complications should the nurse suspect? - ANS
-Fat embolism syndrome
, The nurse should identify the triad of neurological changes, petechial rash, and hypoxemia as findings of fat embolism
syndrome. Risk factors include multiple fractures and a fracture of a long bone. Male clients are also at greater risk. The
manifestations occur when far globules occlude small blood vessels.
\A nurse in the emergency department is caring for a client who has Addison's disease and reports nausea, vomiting,
diarrhea, and abdominal pain. To prevent an Addisonian crisis, the nurse should prepare to administer which of the
following medications? - ANS -Hydrocortisone
Addison's disease causes adrenal gland hypofunction and inadequate production of glucocorticoids. Acute adrenal
insufficiency is life-threatening and can lead to severe fluid and electrolyte imbalances. Without treatment, sodium levels
fall, and potassium levels increase. Rapid infusion of IV fluids such as 0.9% sodium chloride and IV administer of high
dose corticosteroids such as hydrocortisone are vital to correct the glucocorticoid deficiency.
\A nurse in the PACU is assessing a newly admitted client and observes intercostal retractions and a high-pitched
inspiratory sound. The nurse should identify these findings as manifestations of which of the following complications? -
ANS -Respiratory obstruction
Intercostal retractions and a high-pitched inspiratory noise (i.e. stridor) are manifestations of an airway obstruction caused
by laryngospasm and edema. The nurse should notify the rapid response team and plan to administer racemic
epinephrine.
\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? - ANS -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 an acute care facility is preparing to admit a client who myasthenia gravis. Which of the following supplies
should the nurse place at the client's bedside? - ANS -Oral-nasal suction equipment
A client who has myasthenia gravis is at risk for aspiration due to progressive weakness of the oropharyngeal muscles.
Myasthenia gravis causes muscle weakness due to an autoimmune disease that affects the acetylcholine receptors. The
