ATI RN Adult Medical Surgical Online Practice 2019 B | 100% CORRECT (Q&A), Exams of Nursing

Download ATI RN Adult Medical Surgical Online Practice 2019 B | 100% CORRECT (Q&A) and more Exams Nursing in PDF only on Docsity! A nurse is preparing to administer phenytoin 600 mg PO daily to a client. The amount available is oral solution 125 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) 24 A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse take? place a pressure bag around the flush solution Rationale: The nurse should place a pressure bag around the flush solution of 0.9% sodium chloride because the pressure from an artery is greater than that of the line. An arterial line is not appropriate access for administering antibiotics. The nurse should use the arterial line to obtain arterial blood gas samples and monitor hemodynamic pressures. A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of the following findings should the nurse identify as the priority? Report of sore throat Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a report of a sore throat, which could be a manifestation of an infection. The client is at risk for neutropenia due to myelosuppression; therefore, an infection could lead to sepsis. A nurse is reviewing the medical record of a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect? Facial butterfly rash Rationale: A butterfly rash is a manifestation of SLE. It appears as a dry, red rash on the client's cheeks and nose and can disappear during times of remission. A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of the following findings should the nurse identify as a manifestation of this condition? Pain that increases with passive movement Rationale: The nurse should identify that a client who has compartment syndrome experiences pain that increases with passive movement. Compartment syndrome results from a decrease in blood flow in the extremity caused by a decrease in the muscle compartment size due to a cast that is too tight. A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Which of the following statements made by the client reflects an understanding of the teaching? My joints ache because I have Lyme disease Rationale: Lyme disease is a vector-borne illness transmitted by the deer tick. The disease course occurs in three stages beginning with joint and muscle pain in stage I. If left untreated, these symptoms continue throughout stage II and, by stage III, become A nurse is planning care for a client who is postoperative following a parathyroidectomy. Which of the following actions should the nurse identify as the priority? Place tracheostomy tray at the bedside Rationale: The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to place a tracheostomy tray at the client's bedside in case of airway obstruction. A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect? Low urine specific gravity Rationale: An expected finding for a client who has diabetes insipidus is a urine specific gravity between 1.001 and 1.005. Decreased water reabsorption by the renal tubules is caused by an alteration in antidiuretic hormone release or the kidneys' responsiveness to the hormone. A nurse is providing teaching to a client who has stage II cervical cancer and is scheduled for brachytherapy. Which of the following instructions should the nurse include? You will need to stay still in the bed during each treatment session." Rationale: The nurse should instruct the client that they will need to remain on bed rest with very limited movement because excessive movement can cause the radioactive source to become dislodged. The nurse should instruct the client that there is not excreted radiation between treatments. The nurse should instruct the client that there will likely be between two and five treatments, once or twice each week. The nurse should instruct the client that blood in the urine is an adverse effect of brachytherapy and is not an expected finding. A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following interventions should the nurse include in the plan? Encourage the client to take deep breaths after the procedure. Rationale: After a thoracentesis, the client should deep breathe to re-expand the lung. A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions should the nurse anticipate taking? Slow the infusion rate Rationale: Dyspnea, restlessness, and the onset of crackles during a blood transfusion are manifestations of circulatory overload. The nurse should slow or stop the infusion to improve the client's ability to breathe, place the client in an upright position, and notify the provider. The provider might prescribe a diuretic to alleviate the fluid overload. A nurse is preparing to present a program about prevention of atherosclerosis at a health fair. Which of the following recommendations should the nurse plan to include? (Select all that apply.) Follow a smoking cessation program is correct. Smoking cessation is an important lifestyle modification to prevent atherosclerosis. Maintain an appropriate weight is correct. Preventing obesity through diet and exercise can help to prevent atherosclerosis. Eat a low-fat diet is correct. Eating a low-fat diet decreases LDL cholesterol and can prevent atherosclerosis. Increase fluid intake is incorrect. Increasing intake of fruits, vegetables, and grains can prevent atherosclerosis. Decrease intake of complex carbohydrates is incorrect. Decreasing intake of simple sugars and sweetened foods and increasing complex carbohydrates, such as fiber, can reduce the risk of heart disease. A nurse is caring for a client who has homonymous hemianopsia as a result of a stroke. To reduce the risk of falls when ambulating, the nurse should provide which of the following instructions to the client? Scan the environment by turning your head from side to side." Rationale: Homonymous hemianopsia is the loss of the same visual field in both eyes. Turning their head from side to side helps enlarge a client's visual field. This technique is also useful for the client during mealtimes. A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the following findings is an indication of lung re-expansion? Bubbling in the water seal chamber has ceased. Rationale: Bubbling in the water seal chamber ceases when the lung re-expands. A nurse is providing discharge teaching to a client who is to self-administer heparin subcutaneously. Which of the following statements by the client indicates an understanding of the teaching? I will use an electric razor to shave. Rationale: Heparin is an anticoagulant that places the client at the risk for bleeding. Therefore, the nurse should instruct the client to use an electric razor when shaving to reduce the risk of cuts to the skin. A nurse is providing follow-up care for a client who sustained a compound fracture 3 weeks ago. The nurse should recognize that an unexpected finding for which of the following laboratory values is a manifestation of osteomyelitis and should be reported to the provider? Sedimentation rate. Rationale: An increased sedimentation rate occurs when a client has any type of inflammatory process, such as osteomyelitis. A nurse is performing a preoperative assessment for a client. The nurse should identify that an allergy to which of the following foods can indicate a latex allergy? Avocados. Rationale: Clients who have an avocado allergy might have an allergic reaction or a sensitivity to latex. Allergies to certain fruits, such as strawberries and bananas, can also indicate latex allergy or sensitivity. shellfish allergy = allergic reaction to povidone-iodine. peanut allergy = allergic reaction to propofol. egg allergy = allergic reaction to propofol. A nurse is caring for a client who has DKA. Which of the following findings should indicate to the nurse that the client's condition is improving? Glucose 272 Rationale: A glucose reading less than 300 mg/dL indicates improvement in the client's status. A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following should the nurse plan to administer? Regular insulin 20 units IV. Rationale: DKA is a complication of diabetes mellitus that results in dehydration, ketosis, metabolic acidosis, and elevated blood glucose levels. Management of DKA involves providing hydration, correcting acid-base imbalances, and decreasing blood glucose levels. Regular insulin is a fast-acting insulin that can be effective within 10 min when administered intravenously. A nurse is evaluating the plan of care for four clients after 2 days of hospitalization. The nurse should identify the need to revise the plan for which of the following clients? A client who is postoperative following abdominal surgery and reports feeling that something "popped" when they coughed. Rationale: A feeling of something popping or loosening with coughing might indicate a wound dehiscence. This client will need to have revisions to the plan of care, which can include management of the dehiscence, prevention of evisceration, or possible surgical repair of an evisceration if one occurs. A nurse is providing teaching to a client who has a new prescription for psyllium. Which of the following information should the nurse include in the teaching? Drink 240 mL (8 oz) of water after administration. SN: The client should take the medication after meals to prevent appetite suppression. The client should expect results in 12 to 24 hr and bowel regularity in 2 to 3 days. Reducing dietary fiber intake does not affect medication absorption. However, the client should increase dietary fiber intake for management of chronic constipation. A nurse is assessing a client who is at risk for the development of pernicious anemia resulting from peptic ulcer disease. Which of the following images depicts a condition caused by pernicious anemia? This image depicts glossitis, which can indicate pernicious anemia. Glossitis, a smooth red tongue, is also a manifestation of deficiencies in vitamin B6, zinc, niacin, or folic acid. A nurse is providing discharge instructions to a client who has laryngeal cancer and is receiving radiation therapy. Which of the following statements by the client indicates an understanding of the teaching? "I will avoid direct exposure to the sun." Rationale: The client should avoid exposure of irradiated skin areas to the sun for at least 1 year after completing radiation therapy. Skin in the radiation path is especially sensitive to sun damage. SN: Head and neck radiation can damage the salivary glands and cause dry mouth, which predisposes the client to mucositis. The client should rinse the mouth with plain water or 0.9% sodium chloride. A nurse is admitting a client who has active tuberculosis. Which of the following types of transmission precautions should the nurse initiate? Airborne. Rationale: Airborne precautions are required for clients who have infections due to micro-organisms that can remain suspended in air for lengthy periods of time, such as tuberculosis, measles, varicella, and disseminated varicella zoster. A nurse is reviewing the medical record of a client who has osteomyelitis and a prescription for gentamicin. Which of the following findings from the client's medical record should indicate to the nurse the need to withhold the medication and notify the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) Serum creatinine. Rationale: A client who has an elevated serum creatinine level should not receive gentamicin because the medication is nephrotoxic. A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following nonpharmacological interventions should the nurse suggest to the client to reduce pain? Alternate application of heat and cold to the affected joints. A nurse is assessing a client following the completion of hemodialysis. Which of the following findings is the nurse's priority to report to the provider? Restlessness A nurse is caring for a client who is 4 hr postoperative following an open reduction internal fixation of the right ankle. Which of the following assessment findings should the nurse report to the provider? Extremity cool upon palpation A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the nurse's priority? Temperature 38.9° C (102° F) A nurse is planning care for a client who is having a modified radical mastectomy of the right breast. Which of the following interventions should the nurse include in the plan of care? Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24-hr period. A nurse is teaching a client about the use of transcutaneous electrical nerve stimulation (TENS) for the management of bone cancer pain. The nurse should explain that applying a TENS unit to the painful area has which of the following effects? A tingling sensation replacing the pain A nurse is providing teaching to a client who has a recent diagnosis of constipation- predominant irritable bowel syndrome. Which of the following instructions should the nurse include in the teaching? Consume at least 30 g of fiber daily. A nurse is providing teaching to a client who has AIDS. Which of the following statements by the client indicates an understanding of the teaching? "I will take my temperature once a day." A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation. Which of the following values should the nurse identify as a desired outcome for this therapy? INR 2.5 A nurse is caring for a newly admitted client who has a gastric hemorrhage and is going into shock. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) AdminiSTER o2 Initiate IV therapy Insert an NG tube Administer ranitidine A nurse is assessing heart sounds of a client who reports substernal precordial pain. Identify which of the following sounds the nurse should document in the client's medical record by listening to the audio clip. (Click on the audio button to listen to the clip.) Pericardial friction rub A nurse is teaching a client about osteoporosis prevention. The nurse should instruct the client that which of the following medications can increase their risk for developing osteoporosis? Prednisone A nurse is providing education to a client who is at risk for osteoporosis. Which of the following instructions should the nurse include? Walk for 30 min four times per week. A nurse is teaching a client who has a cardiac dysrhythmia about the purpose of undergoing continuous telemetry monitoring. Which of the following statements by the client reflects an understanding of the teaching? "This identifies if the pacemaker cells of my heart are working properly." A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The client is unable to void on the bedpan. Which of the following actions should the nurse take first? Scan the bladder with a portable ultrasound. A nurse is assessing a client while suctioning the client's tracheostomy tube. Which of the following findings should indicate to the nurse the client is experiencing hypoxia? The client's heart rate increases. A nurse is providing discharge instructions to a client who has active tuberculosis (TB). Which of the following information should the nurse include in the instructions? Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures. A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The client's initial vital signs were heart rate 80/min, blood pressure 130/70 mm Hg, respiratory rate 16/min, and temperature 36° C (96.8° F). Which of the following vital sign changes should alert the nurse that the client might be hemorrhaging? Heart rate 110/min A nurse is caring for a client who has a positive culture for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take? Bathe the client using chlorhexidine solution. A nurse is assessing a client's hydration status. Which of the following findings indicates fluid volume overload? Distended neck veins A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the following instructions should the nurse include? Flex the foot every hour when awake. A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After ensuring a patent airway, which of the following nursing interventions is the priority? Applying oxygen via face mask A nurse in an emergency department is assessing an older adult client who has a fractured wrist following a fall. During the assessment, the client states, "Last week I crashed my car because my vision suddenly became blurry." Which of the following actions is the nurse's priority? Check the client's neurologic status. A nurse is caring for an older adult client who has dementia and requires acute care for a respiratory infection. The client is agitated and is attempting to remove their IV catheter. Which of the following actions should nurse take to avoid restraining the client? Keep the client occupied with a manual activity. A nurse is caring for a client who has terminal cancer. The client tells the nurse, "I wish I could stop these treatments. I am ready to die." Which of the following statements should the nurse make? "Discontinuing with the treatments is your choice if it is your wish to do so." A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? Place personal items, such as pictures, at the client's bedside. A nurse is providing teaching to a client who has asthma about the use of a metered- dose inhaler. The nurse should identify that which of the following client actions indicates an understanding of the teaching? Holding breath for 10 seconds after inhaling A nurse is administering packed RBCs to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction?