ATI RN Adult Medical Surgical Online Practice A Latest Update 2023/2024, Exams of Nursing

Download ATI RN Adult Medical Surgical Online Practice A Latest Update 2023/2024 and more Exams Nursing in PDF only on Docsity! ATI RN Adult Medical Surgical Online Practice A Latest Update 2023/2024 A nurse is providing discharge instructions to a client following an upper gastrointestinal series with barium contrast. Which of the following information should the nurse provide? Increase fluid intake Rationale: Increasing fluid intake will help to prevent constipation. Therefore, the nurse should instruct the client to increase fluid intake to facilitate the elimination of the barium used during the test. A nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. The client is experiencing excessive stools. Which of the following findings is an adverse effect of this medication? Hypokalemia Rationale: Lactulose works by stimulating the production of excess stools to rid the body of excess ammonia. These excessive stools can result in hypokalemia and dehydration. A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first? Instruct the client to allow the machine to breathe for them Rationale: When providing client care, the nurse should first use the least restrictive intervention. Therefore, the first action the nurse should take is to provide verbal instructions and emotional support to help the client relax and allow the ventilator to work. Clients can exhibit anxiety and restlessness when trying to "fight the ventilator." A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate this risk, which of the following dietary alterations should the nurse recommend? Add cabbage to the diet Rationale: To help reduce the risk for colorectal cancer, the client should consume a diet that is high in fiber, low in fat, and low in refined carbohydrates. Brassica vegetables, such as cabbage, cauliflower, and broccoli, are high in fiber. A home health nurse is assigned to a client who was recently discharged from a rehabilitation center after experiencing a right-hemispheric stroke. Which of the following neurologic deficits should the nurse expect to find when assessing the client? (Select all that apply.) Visual spatial deficits Left hemianopsia One-sided neglect Rationale: Visual spatial deficits is correct. Visual spatial deficits and loss of depth perception occur secondary to a right-hemispheric stroke. Left hemianopsia is correct. Left hemianopsia, or blindness in the left half of the visual field, occurs secondary to a right-hemispheric stroke. One-sided neglect is correct. One-sided neglect, or an unawareness of the affected side, occurs secondary to a right-hemispheric stroke. impaired sensation and function within the oral cavity. Therefore, the nurse should place priority on this finding. A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new prescription for metformin. Which of the following statements by the client indicates an understanding of the teaching? "I should take this medication with a meal." Rationale: The client should take metformin with or immediately following meals to improve absorption and to minimize gastrointestinal distress. A nurse is teaching a client who has venous insufficiency about self-care. Which of the following statements should the nurse identify as an indication that the client understands the teaching? "I will wear clean graduated compression stockings every day." Rationale: The client should apply a clean pair of graduated compression stockings each day and clean soiled stockings with mild detergent and warm water by hand. A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurse's priority? Tachycardia Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is tachycardia. Tachycardia is a manifestation of biliary colic, which can lead to shock. The nurse should position the head of the client's bed flat and report this finding immediately to the provider. A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The nurse should postpone the testing and report to the provider which of the following findings? Current medications Rationale: The nurse should review the client's medication record and identify medications, including ACE inhibitors, beta blockers, theophylline, nifedipine, and glucocorticoids, such as prednisone, that can alter the allergy skin test results. These medications can diminish the client's reaction to the allergens. The nurse should notify the provider and instruct the client to discontinue prednisone for 2 weeks before allergy skin testing. A nurse is caring for a group of clients. The nurse should plan to make a referral to physical therapy for which of the following clients? A client who is receiving preoperative teaching for a right knee arthroplasty Rationale: The nurse should make a referral to physical therapy for a client who is receiving preoperative teaching for a knee arthroplasty so the client can begin understanding postoperative exercises and physical restrictions. A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following laboratory findings should the nurse expect? BUN 32 mg/dl Rationale: DKA results in osmotic diuresis and subsequent dehydration. The nurse should expect a client who has DKA to have elevated BUN, creatinine, and specific gravity levels resulting from the excess glucose present in the urine. A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish a ureterostomy. Which of the following statements should the nurse include in the teaching? "You should cut the opening of the skin barrier one-eighth inch wider than the stoma." Rationale: The client should cut the opening of the skin barrier 0.3 cm (1/8-in) wider than the stoma to minimize irritation of the skin from exposure to urine. A nurse is providing teaching for a female client who has recurrent urinary tract infections. Which of the following information should the nurse include in the teaching? Void before and after intercourse Rationale: The nurse should instruct the client to empty her bladder before and after intercourse, which flushes bacteria out of the urinary tract and prevents the occurrence of infection. A nurse and an assistive personnel (AP) are caring for a client who has bacterial meningitis. The nurse should give the AP which of the following instructions? Wear a mask Rationale: Bacterial meningitis requires droplet precautions; therefore, the AP and the nurse should wear a mask when coming within 0.9 m (3 ft) of the client until 24 hr after the client has begun receiving antibiotic therapy. A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take? Place a pillow between the client's legs Rationale: The nurse should place a pillow between the client's legs to prevent hip dislocation. Try to walk at least three times per week for exercise Rationale: The development of a regular exercise routine can improve outcomes in clients who have heart failure. A nurse is caring for a client who has HIV. Which of the following findings indicates a positive response to the prescribed HIV treatment? Decreased viral load Rationale: Viral load testing measures the presence of HIV viral genetic material. Therefore, a decreased viral load indicates a positive response to the prescribed HIV treatment. A nurse is caring for a client who is postoperative following a total hip arthroplasty Which of the following laboratory values should the nurse report to the provider? Hgb 8 g/dL Rationale: The nurse should report an Hgb level of 8 g/dL, which is below the expected reference range and is an indicator of postoperative hemorrhage or anemia. A nurse is assessing a client who has had a plaster cast applied to their left leg 2 hr ago. Which of the following actions should the nurse take? Check that one finger fits between the cast and the leg Rationale: To make sure the cast is not too tight, the nurse should be able to slide one finger under the cast. It is not uncommon for casts to loosen as swelling subsides, but that should not be an issue 2 hr after application. A nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. Which of the following statements by the client indicates an understanding of the teaching? "I am taking this medication to increase my energy level." Rationale: The goal of erythropoietin therapy is to increase the level of hematocrit in clients who have anemia. When the medication is effective, the client should have a decrease in fatigue and an improvement in activity tolerance. A nurse is caring for a client who is undergoing hemodialysis to treat end-stage kidney disease (ESKD). the client reports muscle cramps and a tingling sensation in their hands. Which of the following medications should the nurse plan to administer? Calcium carbonate Rationale: Hypocalcemia is a manifestation of ESKD and an adverse effect of dialysis. Often occurring late in the dialysis session, hypocalcemia can cause the client to experience muscle cramping and tingling to extremities. The nurse should plan to administer a calcium supplement, such as calcium carbonate, as a calcium replacement. 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? Aged cheese Rationale: Foods that contain tyramine, such as aged cheese and sausage, can trigger migraine headaches. A nurse is providing teaching to a female client who has a history of urinary tract infections (UTIs). Which of the following information should the nurse include in the teaching? Take daily cranberry supplements Rationale: The client should take cranberry supplements or drink low-fructose cranberry juice because it contains compounds that adhere to the urinary tract wall, decreasing the risk for developing a UTI. A nurse is performing a dressing change for a client who is recovering from a hemicolectomy. When removing the dressing, the nurse notes that a large part of the bowel is protruding through the abdomen. Which of the following actions should the nurse take first? Call for help Rationale: Evidence-based practice indicates that the nurse should first stay with the client and call for assistance. The client will require emergency surgery and is at risk for shock; therefore, the nurse should obtain immediate assistance. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take? Remain with the client for the first 15 min of the infusion Rationale: The nurse should remain with the client for the first 15 to 30 min of the infusion because hemolytic reactions usually occur during the infusion of the first 50 mL of blood. A nurse is evaluating a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following client statements indicates the client is successfully coping with this change? "I used to never worry about my feet. Now, I inspect my feet every day with a mirror." Rationale: This statement indicates that the client is successfully coping with the change A nurse is providing teaching to an older adult client who has cancer and a new prescription for an opioid analgesic for pain management. Which of the following information should the nurse include in the teaching? "You should void every 4 hours to decrease the risk of urinary retention." Rationale: The nurse should instruct the client to void at least every 4 hr to decrease the risk of urinary retention, which is an adverse effect of opioid analgesics. A nurse is assessing a client following the administration of magnesium sulfate 1 g IV bolus. For which of the following adverse effects should the nurse monitor? Respiratory paralysis Rationale: The nurse should monitor a client who is receiving magnesium sulfate via IV bolus closely as the adverse effects can impact the CNS, the cardiovascular system, and the respiratory system. Respiratory paralysis is a life-threatening adverse effect of magnesium sulfate. A nurse is assessing a male client for an inguinal hernia. Which of the following areas should the nurse palpate to verify that the client has an inguinal hernia? middle/suprapubic answer Rationale: The nurse should palpate this location to assess the client for an inguinal hernia. An inguinal hernia forms from the peritoneum, which contains part of the intestine, and can protrude into the scrotum in men. A nurse is caring for a client who has type 1 diabetes mellitus and has had acute bronchitis for the past 3 days. Which of the following statements should the nurse include when instructing the client? "Take insulin even if you are unable to eat your regular diet." Rationale: The client should continue the prescribed medication regimen when ill to prevent hyperglycemia. A nurse has received change-of-shift report for a group of clients. Which of the following clients should the nurse assess first ? A client who had a myocardial infarction (MI) 4 days ago and is asking for a PRN sublingual nitroglycerin tablet Rationale: When using the stable vs. unstable approach to client care, the nurse should assess this client first. A client who had a myocardial infarction 4 days ago and is asking for a PRN sublingual nitroglycerin tablet could be unstable. This client might be experiencing angina or could be having another MI. A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pneumonia. Which the following assessment findings is the nurse's priority? Increased respiratory secretions Increased respiratory secretions Rationale: Using the airway, breathing, circulation approach to client care, the nurse should determine that the priority assessment finding is increased respiratory secretions. These secretions place the client at risk for aspiration pneumonia due to respiratory muscle weakness caused by the ALS and the pneumonia. A nurse is creating a plan of care for a client who has neutropenia as a result of chemotherapy. Which of the following interventions should the nurse include in the plan? Monitor the client's temperature every 4 hr. Rationale: The nurse should monitor the temperature of a client who has neutropenia every 4 hr because the client's reduced amount of leukocytes greatly increases the client's risk for infection. A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of the medication? Calcium Rationale: Calcium limits the development of osteoporosis in clients who are postmenopausal and works as an antacid. Calcium supplements can interfere with the metabolism of a number of medications, including levothyroxine. The nurse should instruct the client to avoid taking calcium within 4 hr of levothyroxine administration. A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a productive cough. Which of the following actions should the nurse take first? Initiate airborne precautions Rationale: This client is exhibiting manifestations of tuberculosis. The greatest risk in this client situation is for other people in the facility to acquire an airborne disease from this client. Therefore, the first action the nurse should take is to initiate airborne precautions. A nurse in an acute care facility for a client who is at risk for seizures. Which of the following precautions should the nurse implement? Obtain vital signs Rationale: The first action the nurse should take using the nursing process is to assess the client's vital signs. A client who has portal hypertension can develop esophageal varices, which are fragile and can rupture, resulting in large amounts of blood loss and shock. Obtaining vital signs provides information about the client's condition that can contribute to decision making. A nurse is planning care for a client who is undergoing brachytherapy via a sealed vaginal implant to treat endometrial cancer. Which of the following actions should the nurse include in the client's plan of care? Wear a lead apron while providing care to the client Rationale: The nurse should wear a lead apron when providing direct care to provide protection from the radiation source and not turn their back toward the client, because the apron only shields the front of the body. The nurse should also wear a dosimeter film badge to measure radiation exposure. A nurse is caring for a client who has a potassium level of mEq/L. Which of the following assessment findings should the nurse expect? Hypoactive bowel sounds Rationale: Hypokalemia decreases smooth muscle contraction in the gastrointestinal tract leading to decreased peristalsis. 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? Bradycardia Rationale: 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 is providing preoperative teaching for a client who is scheduled for an open cholecystectomy. Which of the following actions should the nurse take? Demonstrate ways to deep breathe and cough Rationale: The nurse should demonstrate deep breathing and coughing exercises and explain the importance of splinting the incision to reduce the risk for respiratory complications. A nurse is caring for a client who has a leg cast and is returning demonstration on the proper use of crutches while climbing stairs. Identify the sequence the client should follow when demonstrating crutch use. 1. Places body weight on the crutches 2. Advance the unaffected leg onto the stair 3. Shifts weight from the crutches to the unaffected leg 4. Brings the crutches and the affected leg up to the stair Rationale: The client should first place their body weight on the crutches. Next, they should advance the unaffected leg onto the stair. Third, they should shift their weight from the crutches to the unaffected leg. Last, they should bring the crutches and the affected leg up to the stair. A nurse in an emergency department is caring for a client who is experiencing a thyroid storm. Which of the following manifestations should the nurse expect? (Select all that apply.) Fever Hypertension Tachycardia Rationale: Fever is correct. The nurse should expect the client to have a fever because of the excessive thyroid hormone release. Hypertension is correct. The nurse should expect one of the early manifestations of thyroid storm to include systolic hypertension because of the excessive thyroid hormone release. Tachycardia is correct. The nurse should expect the client to have tachycardia because of the excessive thyroid hormone release. A nurse is caring for a client who has a prescription for enalapril. The nurse should identify which of the following findings as an adverse effect of the medication? Orthostatic hypotension Rationale: The nurse should identify that dilation of arteries and veins causes orthostatic hypotension, which is an adverse effect of enalapril. A nurse is providing teaching to a client who has irritable bowel syndrome (IBS). Which of the following instructions should the nurse include in the teaching? Increase fiber intake to at least 30 g per day Rationale: Dietary fiber helps produce bulky, soft stools and establish regular bowel patterns. A nurse is caring for a client who has a stage III pressure injury. Which of the following findings contributes to delayed wound healing? Report of a night cough Rationale: The nurse should recognize that a night cough is an early indication of heart failure and report this adverse reaction to the provider. A nurse is reviewing the laboratory results of a client who has cirrhosis. Which of the following laboratory values should the nurse expect? Elevated bilirubin level Rationale: Bilirubin levels reflect the liver's ability to conjugate and excrete bilirubin, a byproduct of the hemolysis of red blood cells. Bilirubin levels rise with liver disease and clinically reflect the client's degree of jaundice. A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. Which of the following prescribed medications should the nurse instruct the client to withhold for 48 hr prior to cardiovesion? Digoxin Rationale: Cardiac glycosides, such as digoxin, are withheld prior to cardioversion. These medications can increase ventricular irritability and put the client at risk for ventricular fibrillation after the synchronized countershock of cardioversion. A nurse is providing teaching to an older adult female client who has stress incontinence and a BMI of 32. Which of the following statements by the client indicates and understanding of the teaching? "I am dieting to lose weight." Rationale: Excess weight creates increased abdominal pressure that can result in stress incontinence A nurse is assessing a client who has Graves' disease. Which of the following images should indicate to the nurse that the client has exophthalmos? Outward protrusion of the eyes Rationale: The nurse should identify an outward protrusion of the eyes as exophthalmos, a common finding of Graves' disease. An overproduction of the thyroid hormone causes edema of the extraocular muscle and increases fatty tissue behind the eye, which results in the eyes protruding outward. Exophthalmos can cause the client to experience problems with vision, including focusing on objects, as well as pressure on the optic nerve. A nurse is caring for a client who has chronic glomerulonephritis with oliguria. Which of the following findings should the nurse identify as a manifestation of chronic glomerulonephritis? Hyperkalemia Rationale: The nurse should identify that a client who has chronic glomerulonephritis can experience hyperkalemia as a result of kidney failure. Kidney failure results in decreased excretion of potassium. A nurse in an emergency department is caring for a client who has full-thickness burns over 20% of their total body surface area. After ensuring a patent airway and administering oxygen, which of the following items should the nurse prepare to administer first? IV fluids Rationale: After establishing that the client's airway is secure and administering oxygen, evidence-based practice indicates that the nurse should prepare to administer IV fluids to provide circulatory support. A nurse is caring for a client who is having a seizure. Which of the following interventions is the nurse's priority? Turn the client to the side Rationale: The greatest risk to this client is hypoxia from an impaired airway. Therefore, the priority intervention the nurse should take is to place the client in a side-lying position to prevent aspiration. A nurse is caring for a client 1 hr following cardiac catheterization. The nurse notes the formation of a hematoma at the insertion site and decreased pulse rate in the affected extremity. Which of the following interventions is the nurse's priority? Apply firm pressure to the insertion site Rationale: The greatest risk to the client is bleeding. Therefore, the priority intervention is for the nurse to apply firm pressure to the hematoma to stop the bleeding. A nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. Which of the following statements should the nurse identify as an indication that the client understands the teaching? "I will use my hands rather than a washcloth to clean the radiation area." Rationale: The client should gently wash the radiation area with their hands using warm water and mild soap to protect the skin from further irritation. A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place which of the following items at the client's bedside?