ATI Adult Medical Surgical 2019

ATI Med-Surg

 

1.            A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching?

1)            Take temperature once a day.

2)            Wash the armpits and genitals with a gentle cleanser daily.

3)            Change the litter boxes while wearing gloves.

4)            Wash dishes in warm water.

2.            A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client’s secretions?

1)            Provide humidified oxygen.

2)            Perform chest physiotherapy prior to suctioning.

3)            Prelubricate the suction catheter tip with sterile saline when suctioning the airway.

4)            Hyperventilate the client with 100% oxygen before suctioning the airway..

 

3.            Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client’s comfort?

1)            Rub the client’s feet briskly for several minutes.

2)            Obtain a pair of slipper socks for the client.

3)            Increase the client’s oral fluid intake.

4)            Place a moist heating pad under the client’s feet.

 

4.            A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for the nurse report to the provider?

1)            Emesis of 100 mL

2)            Oral temperature of 37.5° C (99.5° F)

3)            Thick, red-colored urine

4)            Pain level of 4 on a 0 to 10 rating scale

 

5.            A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of the hypothermia blanket?

1)            Shivering

2)            Infection

3)            Burns

4)            Hypervolemia

 

6.            A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

1)            “I will carry a complex carbohydrate snack with me when I exercise.”

2)            “I should exercise first thing in the morning before eating breakfast.”

3)            “I should avoid injecting insulin into my thigh if I am going to go running.”

4)            “I will not exercise if my urine is positive for ketones.”

 

7.            A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first?

1)            Cover the client’s wound with a moist, sterile dressing.

2)            Have the client lie supine with knees flexed.

3)            Check the client’s vital signs.

 

4)            Inform the client about the need to return to surgery.

 

 

8.            A nurse is collecting data from a client who has alcohol use disorder and is experiencing metabolic acidosis. Which of the following manifestations should the nurse expect?

1) Cool, clammy skin. 2) Hyperventilation

3)            Increased blood pressure

4)            Bradycardia

 

9.            A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching?

1)            Avoid bending at the waist.

2)            Remove the eye shield at bedtime.

3)            Limit the use of laxatives if constipated.

4)            Seeing flashes of light is an expected finding following extraction.

 

10. A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first?

1)            Suggest that the client rests before eating the meal.

2)            Request a dietary consult.

3)            Check the client’s vital signs.

4)            Request an order for an antiemetic.

 

11. A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the client’s wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found?

1)            Sanguineous

2)            Serous

3)            Serosanguineous

4)            Purulent

 

12. A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent postoperative complications which of the following actions should be reinforced during the teaching?

1)            Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises.

2)            Place the client’s affected leg into the CPM machine with the machine in the flexed position.

3)            Place the client into a high Fowler’s position when initiating the CPM exercises.

4)            Align the joints of the CPM machine with the knee gatch in the client’s bed.

 

13. A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.)

1)            Dyspnea

2)            Barrel chest

3)            Clubbing of the fingers 4) Shallow respirations

5) Bradycardia

 

14. A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client’s right nostril. Which of the following actions should the nurse take first?

 

1)            Take the client’s temperature.

2)            Place a dressing under the client’s nose.

3)            Notify the charge nurse.

4)            Test the drainage for glucose.

 

15. A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia?

1)            Monitor for elevated blood pressure.

2)            Provide analgesia for headaches.

3)            Prevent bladder distention.

4)            Elevate the client’s head.

 

16. A nurse is caring for a client who is being evaluated for endometrial cancer. Which of the following findings should the nurse expect the client to report?

1)            Hot flashes

2)            Recurrent urinary tract infections

3)            Blood in the stool

4)            Abnormal vaginal bleeding

 

17. A nurse is caring for a client following an open reduction and internal fixation of a fractured femur. Which of the following findings is the nurse’s priority?

1)            Altered level of consciousness

2)            Oral temperature of 37.7° C (100° C)

3)            Muscle spasms

4)            Headache

 

18. A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge resection of the left lung and has a chest tube to suction. Which of the following is the priority finding the nurse should report to the provider?

1)            Abdomen is distended

2)            Chest tube drainage of 70 mL in the last hour

3)            Subcutaneous emphysema is noted to the left chest wall

4)            Pain level of 6 on a 0 to 10 scale

 

19. A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching?

1)            Change the ostomy pouch daily.

2)            Empty the ostomy pouch when it is 2/3 full.

3)            Trim the opening of the ostomy seal to be 1/2 in. wider than the stoma.

4)            Apply lotion to the peristomal skin when changing the ostomy pouch.

 

20. A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland. Which of the following actions should the nurse include in the plan?

1)            Position the client supine while in bed.

2)            Change the nasal drip pad as needed.

3)            Encourage frequent brushing of teeth.

4)            Encourage the client to cough every 2 hr following surgery.

 

21. A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily following a myocardial infarction. The nurse should instruct the client that aspirin is prescribed for clients who have coronary artery disease for which of the following effects?

1)            To provide analgesia

 

2)            To reduce inflammation

3)            To prevent blood clotting

4)            To prevent fever

 

 

 

 

22. A nurse is collecting data from a client who has open-angle glaucoma. Which of the following findings should the nurse expect?

1)            Loss of peripheral vision

2)            Headache

3)            Halos around lights

4)            Discomfort in the eyes

 

23. A nurse is collecting data from a client who has acute gastroenteritis. Which of the following data collection findings should the nurse identify as the priority?

1)            Weight loss of 3% of total body weight.

2)            Blood glucose 150 mg/dL.

3)            Potassium 2.5 mEq/L

4)            Urine specific gravity 1.035

 

24. A nurse is reinforcing discharge teaching with a client who had a total abdominal hysterectomy and a vaginal repair. Which of the following statements by the client indicates a need for further teaching?

1)            “I should increase my intake of protein and vitamin C.”

2)            “I will no longer have menstrual periods.”

3)            “Once I am able to resume sexual activity, I can use a water-based lubricant if I experience discomfort.”

4)            “I will take a tub bath instead of a shower.”

 

25. A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction. Which of the following actions should the nurse take?

1) Loosen the knots on the ropes if the client is experiencing pain. 2) Ensure the client’s weights are hanging freely from the bed.

3)            Check the client’s bony prominences every 12 hr.

4)            Cleanse the client’s pin sites with povidone-iodine.

 

26. A nurse in a provider’s office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include?

1)            Take this medication between meals.

2)            Limit intake of Vitamin C while taking this medication.

3)            Take this medication with milk.

4)            Limit intake of whole grains while taking this medication.

 

27. A nurse in a provider’s office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include?

1)            Take this medication between meals.

2)            Limit intake of Vitamin C while taking this medication.

3)            Take this medication with milk.

4)            Limit intake of whole grains while taking this medication.

 

28. A nurse is reviewing the plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse recommend?

1)            Apply topical antifungal agents.

2)            Apply fresh ice packs every 4 hr.

3)            Wash daily with an antibacterial soap.

4)            Keep draining lesions uncovered to air dry.

 

 

 

 

29. A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy established. Which of the following instructions should the nurse include in the teaching?

1)            Empty the pouch immediately after meals.

2)            Change the entire appliance once a day.

3)            Limit fluid intake.

4)            Avoid medications in capsule or enteric form.

 

30. A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for an escharotomy and wants to know what the procedure involves. Which of the following statements is appropriate for the nurse to make?

1)            “An escharotomy surgically removes dead tissue.”

2)            “A cannula will be inserted into the bone to infuse fluids and antibiotics.”

3)            “A piece of skin will be removed and grafted over the burned area.”

4)            “Large incisions will be made in the burned tissue to improve circulation.”

 

31. A nurse is collecting data from a client who has a possible cataract. Which of the following manifestations should the nurse expect the client to report?

1)            Decreased color perception

2)            Loss of peripheral vision

3)            Bright flashes of light

4)            Eyestrain

 

32. A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the following interventions should the nurse include in the plan of care?

1)            Measure abdominal girth daily.

2)            Use sterile water to irrigate the nasogastric tube..

3)            Maintain the client in Fowler’s position.

4)            Moisten the client’s lips with lemon-glycerin swabs.

 

33. A nurse is caring for a client who has Cushing’s syndrome. Which of the following clinical manifestations should the nurse expect to observe? (Select all that apply.)

1)            Buffalo hump

2)            Purple striations

3)            Moon face

4)            Tremors

5)            Obese extremities

 

34. A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following actions should the nurse take?

1)            Provide a diet high in protein.

2)            Provide ibuprofen for retroperitoneal discomfort.

3)            Monitor intake and output hourly

 

4)            Encourage the client to consume at least 2 L of fluid daily.

 

35. A nurse is reinforcing teaching about an esophagogastroduodenoscopy with a client who has upper gastric pain. Which of the following statements should the nurse include in the teaching?

1)            “A flexible tube is introduced through the nose during the procedure.”

2)            “During the procedure you are in a sitting position.”

3)            “You will remain NPO for 8 hours before the procedure.”

4)            “You will be awake while the procedure is performed.”

 

 

36. A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record?

1)            Aura phase

2)            Presence of automatisms

3)            Postictal phase

4)            Presence of absence seizures

 

37. A nurse is reinforcing teaching with a client who reports right shoulder pain following a laparoscopic cholecystectomy. Which of the following statements should the nurse make?

1)            “The pain results from lying in one position too long during surgery.”

2)            “The pain occurs as a residual pain from cholecystitis.”

3)            “The pain will dissipate if you ambulate frequently.”

4)            “The pain is caused from the nitrous dioxide injected into the abdomen.”

 

38. A nurse is checking the suction control chamber of a client’s chest tube and notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?

1)            Notify the provider.

Answer Rationale:

The nurse should check for kinks and take other measures before notifying the provider.

2)            Verify that the suction regulator is on.

3)            Continue to monitor the client because this is an expected finding.

4)            Milk the chest tube to dislodge any clots in the tubing that may be occluding it.

 

39. A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.)

1)            Encourage fluid intake.

2)            Monitor the puncture site for hematoma.

3)            Insert a urinary catheter.

4)            Elevate the client’s head of bed.

5)            Apply a cervical collar to the client.

 

40. A nurse is assisting with the care of a client who is postoperative following surgical repair of a fractured mandible. The client’s jaw is wired shut to repair and stabilize the fracture. The nurse should recognize which of the following is the priority action?

1)            Relieve the client’s pain.

2)            Check the client’s pressure points for redness.

3)            Provide oral hygiene.

4)            Prevent aspiration.

 

41. A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect?

 

1)            A dry raised rash

2)            Excessive salivation

3)            Periorbital edema

4)            Hardened skin

 

42. A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take?

1)            Instruct the client to tilt her head back when she swallows.

2)            Place food on the left side of the client’s mouth.

3)            Add thickener to fluids.

4)            Serve food at room temperature.

 

43. A nurse is caring for a client who has partial-thickness and full-thickness burns of his head, neck, and chest. The nurse should recognize which of the following is the priority risk to the client?

1)            Airway obstruction

2)            Infection

3)            Fluid imbalance

4)            Contractures

 

44. A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis and is to start taking neostigmine. Which of the following instructions should the nurse include in the teaching?

1)            Take the medication 45 minutes before eating.

2)            Expect diaphoresis as a side effect of the neostigmine.

3)            If a medication dose is missed, wait until the next scheduled dose to take the medication.

4)            Treat nasal rhinitis with an over-the-counter antihistamine.

 

45. A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse notes there has not been any urinary output in the last hour. Which of the following actions should the nurse perform first?

1)            Notify the provider.

2)            Administer a prescribed analgesic.

3)            Offer oral fluids.

4)            Determine the patency of the tubing.

 

46. A nurse is caring for a client scheduled for a bone marrow biopsy. The client expresses fear about the procedure and asks the nurse if the biopsy will hurt. Which of the following responses should the nurse make?

1)            “You must be very worried about what the biopsy will show.”

2)            “You’ll be asleep for the whole biopsy procedure and won’t be aware of what’s happening.”

3)            “Your provider scheduled this, so she will want to know you still have questions about the procedure.”

4)            “The biopsy can be uncomfortable, but we will try to keep you as comfortable as possible.”

 

47. A nurse is assisting with planning care for a client who is recovering from a left-hemispheric stroke. Which of the following interventions should the nurse include in the plan?

1)            Control impulsive behavior.

2)            Compensate for left visual field deficits.

3)            Re-e

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