MED SURG- PROCTORED ATI MIAMI DADE COLLEGE WITH ACTUAL
QUESTIONS AND CORRECT ANSWERS
An older adult 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? - CORRECT ANSWERS-Urine
Specific gravity 1.045
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 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? - CORRECT ANSWERS-Aged cheese
Foods that contain tyramine, such as aged cheese and sausage, can trigger
migraine headaches.
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? - CORRECT
ANSWERS-"You should cut the opening of the skin barrier one-eight inch wider
than the stoma."
The client should cut the opening of the skin barrier 0.3 cm (1/8in) wider than
the stoma to minimize irritation of the skin from exposure to urine.
,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? -
CORRECT ANSWERS-Calcium
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 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? - CORRECT ANSWERS-
History of asthma
A client who has a history of asthma has a greater risk of reacting to the contrast
dye used during the procedure. Other conditions that can result in a reaction to
contrast media include allergies to foods, such as shellfish, eggs, milk, and
chocolate.
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? - CORRECT ANSWERS-Bradycardia
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 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?
- CORRECT ANSWERS-Use a 30-mL syringe
The nurse should use a 30-mL to 60-mL syringe with an 18- or 19- gauge catheter
to deliver the ideal pressure of 8 pounds per square inch (psi) when irrigating a
wound. To maintain healthy granulation tissue, the wound irrigation should be
delivered at between 4 and 15 psi.
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 expect? - CORRECT ANSWERS-Administer
an opioid analgesic to the client.
The nurse should expect a prescription for an opioid analgesic to promote
comfort following a rattlesnake bite.
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). - CORRECT ANSWERS-Current medications
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 a caring for a client who is on bed rest and has a new prescription for
enoxaparin subcutaneous. Which of the following actions should the nurse
take? - CORRECT ANSWERS-Inject the medication into the anterolateral
abdominal wall.
The nurse should inject the medication into the anterolateral or posterolateral
abdominal wall to enhance medication absorption and prevent hematoma
formation.
A nurse is caring for a client who has a stage III pressure injury. Which if the
following findings contribute to delayed wound healing? - CORRECT
ANSWERS-Urine output 25 mL/hr
Urinary output reflects fluid status. Inadequate urine output can indicate
dehydration, which can delay wound healing.
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
500kcal/L. The IV pump should be set at how many mL/hr? (Rounding to the
nearest whole number.) - CORRECT ANSWERS-167 mL/hr
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? - CORRECT ANSWERS-Add cabbage to the diet.
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.
QUESTIONS AND CORRECT ANSWERS
An older adult 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? - CORRECT ANSWERS-Urine
Specific gravity 1.045
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 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? - CORRECT ANSWERS-Aged cheese
Foods that contain tyramine, such as aged cheese and sausage, can trigger
migraine headaches.
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? - CORRECT
ANSWERS-"You should cut the opening of the skin barrier one-eight inch wider
than the stoma."
The client should cut the opening of the skin barrier 0.3 cm (1/8in) wider than
the stoma to minimize irritation of the skin from exposure to urine.
,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? -
CORRECT ANSWERS-Calcium
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 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? - CORRECT ANSWERS-
History of asthma
A client who has a history of asthma has a greater risk of reacting to the contrast
dye used during the procedure. Other conditions that can result in a reaction to
contrast media include allergies to foods, such as shellfish, eggs, milk, and
chocolate.
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? - CORRECT ANSWERS-Bradycardia
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 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?
- CORRECT ANSWERS-Use a 30-mL syringe
The nurse should use a 30-mL to 60-mL syringe with an 18- or 19- gauge catheter
to deliver the ideal pressure of 8 pounds per square inch (psi) when irrigating a
wound. To maintain healthy granulation tissue, the wound irrigation should be
delivered at between 4 and 15 psi.
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 expect? - CORRECT ANSWERS-Administer
an opioid analgesic to the client.
The nurse should expect a prescription for an opioid analgesic to promote
comfort following a rattlesnake bite.
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). - CORRECT ANSWERS-Current medications
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 a caring for a client who is on bed rest and has a new prescription for
enoxaparin subcutaneous. Which of the following actions should the nurse
take? - CORRECT ANSWERS-Inject the medication into the anterolateral
abdominal wall.
The nurse should inject the medication into the anterolateral or posterolateral
abdominal wall to enhance medication absorption and prevent hematoma
formation.
A nurse is caring for a client who has a stage III pressure injury. Which if the
following findings contribute to delayed wound healing? - CORRECT
ANSWERS-Urine output 25 mL/hr
Urinary output reflects fluid status. Inadequate urine output can indicate
dehydration, which can delay wound healing.
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
500kcal/L. The IV pump should be set at how many mL/hr? (Rounding to the
nearest whole number.) - CORRECT ANSWERS-167 mL/hr
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? - CORRECT ANSWERS-Add cabbage to the diet.
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.
