ATI RN Medical Surgical Online Practice Assessment 2019 A With Complete Solution, Exams of Health sciences

Download ATI RN Medical Surgical Online Practice Assessment 2019 A With Complete Solution and more Exams Health sciences in PDF only on Docsity! ATI RN Medical Surgical Online Practice Assessment 2019 A With Complete Solution 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 stores to rid the body of excess ammonia. These excessive stores can result in a hypo kalemia 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 in emotional support to help the client relax and allow the ventilator to work. Clients can exhibit anxiety and restlessness we're 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 all 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 and loss of depth perception occur secondary to a right hemispheric stroke. Left hemianopsia, or blindness in the left half of the visual field, occur secondary to right hemispheric stroke. One-sided neglect, or in unawareness of the affected side, occur secondary to a right hemispheric stroke. A nurse is caring for a client who has viral pneumonia. The client's pulse oximeter readings have fluctuated between 79% and 88% for the last 30 min. Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen? - Nonrebreather mask Rationale: The nurse should initiate a nonrebreather mask to deliver between 80% to 95% oxygen to the client. A client who has an unstable respiratory status should receive oxygen via non-rebreather mask. A nurse is caring for a client who has bilateral pneumonia and an SaO2 of 85%. The client has dyspnea with a productive cough and is using accessory muscles to breathe. Which of the following actions should the nurse take first? - Place the client in high-Fowler's position. Rationale: the greatest risk to this client is injury from airway obstruction. Therefore, their priority intervention the nurse should take us to move the client into high Fowlers position. High Fowlers position facilitate long expansion and improves been elation and gas exchange A nurse is planning care for a client who has extensive burn injuries and is immunocompromised. Which of the following precautions should the nurse include in the plan of care to prevent a Pseudomonas aeruginosa infection? - Avoid placing plants or flowers in the client's room. Rationale: live plants can harbor P. Aeruginosa, And this bacterium can infect burn moons and cause life-threatening complications. The nurse should ensure no one brings live plants or flowers into the clients room. An older adult client is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration? - Urine specific gravity 1.045 Rationale: a urine specific gravity greater than 1.030 indicates a decrease in urine volume and an increase in osmolarity, which is a manifestation of hypertonic dehydration. 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 nurse expect? - Administer an opioid analgesic to the client. Rationale: the nurse should expect a prescription for an opioid analgesic to promote comfort following a rattlesnake bite. A nurse is assessing a client who has had a suspected stroke. The nurse should place the priority on which of the following findings? - Dysphagia Rationale: dysphasia indicates that this client is at greatest risk for aspiration due to impaired sensation and function within the oral cavity. Therefore, the nurse should place priority on this finding. Extra- This patient is also expected to have elevated Emily's, alkaline phosphatase, and bilirubin levels. 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 prevent constipation. So by instructing the client to increase fluid intake helped facilitate the Elimination of barium use during this test. A nurse is assessing a client who had extracorporeal shock wave lithotripsy (ESWL) 6 hr ago. Which of the following findings should the nurse expect? - Stone fragments in the urine Rationale: ESWL is an effort to break the calculi so that the fragments passed down the ureter, Into the bladder, and through the urethra during avoiding. Following the procedure, the nurse should stream the clients urine to confirm the passage of the stones. A nurse is assessing a group of clients for indications of role changes. The nurse should identify that which of the following clients is at risk for experiencing a role change? - A client who has multiple sclerosis and is experiencing progressive difficulty ambulating. Rationale: the nurse should identify that progression of a neurological disease such as multiple sclerosis can lead to a rule change as the client becomes less independent. A nurse is caring for a client who has a new diagnosis of hyperthyroidism. Which of the following is the priority assessment finding that the nurse should report to the provider? - Blood pressure 170/80 mm Hg Rationale: defining of a systolic blood pressure Of 170 mmHg Can indicate that the client is at risk for a thyroid storm. A nurse is providing discharge instructions to a client who has a partial-thickness burn on the hand. Which of the following instructions should the nurse include? - Wrap fingers with individual dressings. Rationale: this allows for functional use of the hand while healing occurs. The nurse should also instructed client to perform range of motion exercises to each finger every hour while awake to promote function of the injured hand. A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching? - "I will monitor my blood pressure while taking this medication." Rationale: hypertension is a common adverse effect and can lead to hypertensive encephalopathy. A nurse is providing discharge teaching to a client who has heart failure and a new prescription for a potassium-sparing diuretic. Which of the following information should the nurse include in the teaching? - 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 barrel genetic material. Therefore, a decrease 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: this 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 underneath the cast. It is not uncommon for cast to loosen the swelling subsides, but That should not be an issue two hours 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 and 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 a client to experience muscle cramping and tingling to the 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 age she's in sausage, can trigger migraines 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: this practice indicates that the nurse should first staywith a client and call for assistance. The client required emergency surgery and is at risk for shock; 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: remaining with the client for the first 15 to 30 minutes of 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 the change? - "I used to never worry about my feet. Now, I inspect my feet every day with a mirror." A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which of the following findings indicates that the client is experiencing increased intracranial pressure (ICP)? (Select all that apply.) - Sleepiness, Widening pulse pressure, Decerbrate posturing A nurse is planning to provide discharge teaching for the family of an older adult client who has hemianopsia and is at risk for falls. Which of the following instructions should the A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for omeprazole. The nurse should instruct the client that the medication provides relief by which of the following actions? - Suppressing gastric acid production A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV contrast agent. The nurse should identify that which of the following findings requires further assessment? - History of asthma A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take first? - Obtain vital signs. 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. A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following assessment findings should the nurse expect? - Hypoactive bowel sounds 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 intercranial pressure from a Trumatic brain injury can develop symptoms of the Cushing's triad which includes bradycardia, 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. 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. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) - Places body weight on the crutches. Advances the unaffected leg onto the stair. Shifts weight form the crutches to the unaffected leg. Brings 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 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 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. A nurse is caring for a client who has a stage III pressure injury. Which of the following findings contributes to delayed wound healing? - Urine output 25 mL/hr A nurse is caring for a client who is experiencing supraventricular tachycardia. Upon assessing the client, the nurse observes the following findings: heart rate 200/min, blood pressure 78/40 mm Hg, and respiratory rate 30/min. Which of the following actions should the nurse take? - Perform synchronized cardioversion. A nurse is caring for a client who presents to a clinic for a 1-week follow-up visit after hospitalization for heart failure. Based on the information in the client's chart, which of the following findings should the nurse report to the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) - Heart rate 55/min A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure injury. Which of the following actions should the nurse take? - Use a 30-mL syringe. A nurse is caring for a client who has a new prescription for total parenteral nutrition (TPN). The client is to receive 2,000 kcal per day. The TPN solution has 500 kcal/L. The IV pump should be set at how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) - 167 A nurse is caring for a client who is receiving morphine for daily dressing changes. The client tells the nurse, "I don't want any more morphine because I don't want to get addicted." Which of the following actions should the nurse take? - Instruct the client on alternative therapies for pain reduction. A nurse is planning care to decrease psychosocial health issues for a client who is starting dialysis treatments for chronic kidney disease. Which of the following interventions should the nurse include in the plan? - Tell the client that it is possible to return to similar previous levels of activity. A nurse in a provider's office is assessing a client who has hypertension and takes propranolol. Which of the following findings should indicate to the nurse that the client is experiencing an adverse reaction to this medication? - Report of a night cough 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 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 cardioversion? - Digoxin 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 an understanding of the teaching? - "I am dieting to lose weight." 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? - D, with the bulging scary eyes A nurse is caring for a client has who has chronic glomerulonephritis with oliguria. Which of the following findings should the nurse identify as a manifestation of chronic glomerulonephritis? - Hyperkalemia 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 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. A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions is the nurse's priority? - Apply firm pressure to the insertion site. 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." 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? - Suction machine A nurse is teaching a class about client rights. Which of the following instructions should the nurse include? - A client should sign an informed consent before receiving a placebo during a research trial.