Nursing Assessments and Teachings, Exams of Nursing

Download Nursing Assessments and Teachings and more Exams Nursing in PDF only on Docsity! ATI RN Adult Medical Surgical Practice B 2024 Questions with SOLUTIONS FINAL EXAM PREDICTOR!! A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect? - SOLUTION Hair loss on the lower legs 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? - SOLUTION "I will use my hands rather than a washcloth to clean the radiation area. A nurse at a provider's office is caring for a client who is 2 weeks postoperative following a gastrectomy. A nurse is providing teaching for the client. Which of the following instructions should the nurse include? Select all that apply. - SOLUTION Avoid drinking fluids with meals Eat several small meals Consume high-protein snacks Avoid highly seasoned foods A nurse is caring for a client who is scheduled for a right knee arthroplasty. The nurse provided preoperative teaching to the client. Which of the following statements by the client indicates an understanding of the teaching? Select all that apply. - SOLUTION "I will need to do the breathing exercises every 1 to 2 hours after the surgery" "I will be sure to ask for pain medication before my knee starts to hurt too bad" "I will probably be going home with a walker" 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 nurse include? - SOLUTION Remind the client to scan their complete range of vision during ambulation. 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? - SOLUTION Urine specific gravity 1.045 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? - SOLUTION 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? - SOLUTION Heart rate 110/min. A nurse is caring for a client who is 4 hr postoperative following a total vaginal hysterectomy. Click to highlight the findings the nurse should report to the provider immediately. - SOLUTION Perineal pad saturated with blood, large clots present Change of blood pressure, heart rate of 102/min A nurse is caring for a client who has HIV. Which of the following findings indicates a positive response to the prescribed HIV treatment? - SOLUTION Decreased viral load 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? - SOLUTION Try to walk at least three times per week for exercise. 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 A nurse is providing teaching to a client who has a history of urinary tract infections (UTIS). Which of the following information should the nurse include in the teaching? - SOLUTION Take daily cranberry supplements.. A nurse is reviewing the laboratory results of a client who has AIDS and is taking amphotericin B for a fungal infection. The nurse should identify that which of the following values is an indication of an adverse effect of the medication? - SOLUTION BUN 34 mg/dL 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? - SOLUTION Bubbling in the water seal chamber has ceased. 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? - SOLUTION 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 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? - SOLUTION Check that one finger fits between the cast and the leg. 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.) - SOLUTION 24 mL The nurse is providing care for the client. The nurse has completed the assessment and is reviewing the findings in the EMR. Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again. - SOLUTION 12 % weight loss over 2 months Muscle guarding and tenderness in right lower quadrant of abdomen Abdominal firmness and rigidity Abdominal pain rate of 8 Hypoactive bowel sounds Report of anorexia Temperature of 38.5 C (101.4 F) A nurse is caring for a client. The nurse has completed their performing an assessment of the client and reviewing the client's EMR. (For each of the client's assessment finding, click to specify if the finding is consistent with appendicitis or Crohn's disease. Each finding may support more than one disease process.) - SOLUTION Appendicitis - Pain location, temperature, GI concerns Crohn's Disease - Stool color, pain location, temperature, GI concerns A nurse is caring for a client. Complete the following sentence by using the lists of options. - SOLUTION After reviewing the findings in the client's medical record, the nurse should first address the client's ABDOMINAL FINDINGS followed by the client's PAIN RATING The nurse is providing care for the client. The nurse is planning care for the client. (For each potential provider's prescription, click to specify if each potential prescription is anticipated or contraindicated for the client.) - SOLUTION Anticipate - Obtain blood cultures, insert NG, obtain vitals Contraindicated - Bolus fluids The nurse is providing care for the client. A nurse is reviewing the client's electronic medical record (EMR) and the provider's prescriptions. Which of the following actions should the nurse take? Select the 3 actions that the nurse should take. - SOLUTION Administer gentamicin 100 mg IV. Administer client's PO medication with a sip of water. Ensure that the client has provided informed consent. The nurse is providing care for the client. A nurse is providing discharge teaching with the client. Which of the following statements made by the client indicates an understanding of the teaching? (Select all that apply.) - SOLUTION "I should schedule several rest periods throughout the day." "I should notify my provider if my temperature is higher than 101 degrees Fahrenheit." 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? - SOLUTION Calcium 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? - SOLUTION Increase fiber intake to at least 30 g per day. 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? - SOLUTION Nonrebreather mask A nurse is providing discharge teaching about infection prevention to a client who is receiving chemotherapy. Which of the following statements by the client indicates understanding of the teaching? - SOLUTION "I can ask a friend to change my cats litter box." A nurse is caring for an 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? - SOLUTION Keep the client occupied with a manual activity. 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 Client is diaphoretic A nurse is caring for a client. A nurse is prioritizing client care. Complete the following sentence by using the lists of options. - SOLUTION The nurse should first address the client's oxygen saturation followed by the client's temperature. A nurse is caring for a client. The nurse is planning care for the client. For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client. - SOLUTION Anticipated - Obtain sputum, acetaminophen, cough and deep breathe, administer O2 Nonessential - Neuro checks, famotidine Contraindicated - Limit fluid intake A nurse is caring for a client. The nurse is reviewing the client's medical record. Select the 3 findings that require nursing intervention. - SOLUTION Potassium level WBC count Temperature A nurse is caring for a client. The nurse is reviewing the client's medical record from Day 5. Click to highlight the findings below that indicate the client is improving. To deselect a finding, click on the finding again. - SOLUTION Heart rate 72/min Respiratory rate 20/min Blood pressure 128/56 mm Hg Oxygen saturation 95% on room air A nurse is planning discharge teaching for a client who has an external fixation device for a fracture of the lower extremity. Which of the following instructions should the nurse include in the plan of care? - SOLUTION Use crutches with rubber tips. 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? - SOLUTION Avocados A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron supplement. Which of the following statements by the client indicates an understanding of the teaching? - SOLUTION "I will eat more high-fiber foods." A nurse is planning care for a client who has a sealed radiation implant for cervical cancer. Which of the following interventions should the nurse include in the plan of care? - SOLUTION Keep a lead-lined container in the client's room. A nurse is providing dietary teaching to a client who is postoperative following a thyroidectomy with removal of the parathyroid glands. The nurse should instruct the client to include which of the following foods that has the greatest amount of calcium in their diet? - SOLUTION 12 almonds A nurse is checking the ECG rhythm strip for a client who has a temporary pacemaker. The nurse notes a pacemaker artifact followed by a QRS complex. Which of the following actions should the nurse take? - SOLUTION Document that depolarization has occurred. 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? - SOLUTION "My joints ache because I have Lyme disease." 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? - SOLUTION INR 2.5 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? - SOLUTION "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 is receiving mechanical ventilation via a tracheostomy tube. The nurse should recognize that which of the following complications is associated with long-term mechanical ventilation? - SOLUTION Stress ulcers 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.) - SOLUTION Visual spatial deficits Left hemianopsia One-sided neglect A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurse's priority? - SOLUTION Tachycardia A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following should the nurse plan to administer? - SOLUTION Regular insulin 20 units IV bolus 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? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) - SOLUTION Current medications 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? - SOLUTION Administer an opioid analgesic to the client.