Exam (elaborations) ATI Med-Surg Practice A Key

Exam (elaborations) ATI Med-Surg Practice A Key 1. 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 2. 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? - Visual spatial deficits - Left hemianopsia - One-sided neglect 3. 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. - Nonrebreather mask 4. 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. - Place the client in high- Fowler’s position 5. 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 6. 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 7. A nurse in an emergency department is reviewing the provider’s prescription for a client who sustained a rattlesnake bite to the lower leg. - Administer an opioid analgesic to the client 8. 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 9. A nurse is teaching a young adult client how to perform testicular self-examination. Which of the following instructions should the nurse include? - Roll each testicle between the thumb and fingers 10. 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? ATI Med-Surg Practice A Key - I should take this medication with a meal 11. 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.” 12. A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurse’s priority? - Tachycardia 13. 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 14. 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 15. A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which for the following laboratory findings should the nurse expect? - BUN 32 mg/dL 16. 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-eight inch wider than the stoma” 17. 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. 18. 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 19. 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. 20. A nurse in a provider’s office is assessing a client who has migraine headaches and is taking feverfew to prevent headaches. The nurse should identify that which of the following client medications interacts with feverfew? - Naproxen 21. A nurse is caring for a client who has pancreatitis. The nurse should expect which of the following laboratory results to be below the expected reference range? - Calcium 22. 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 23. 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 24. 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. 25. 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 26. 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 27. 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. 28. 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 29. 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 30. 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 31. A nurse is assessing a client who has had a plaster cast applied to their left leg 2 hr ago. - Check that one finger fits between the cast and the leg 32. A nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. - “I am taking this medication to increase my energy level.” 33. 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. - Calcium carbonate 34. 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 35. A nurse is providing teaching to a female client who has a history of urinary tract infections (UTIs). - Take daily cranberry supplements. 36. 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. - Call for help 37. A nurse is preparing to administer a unit of packed RBCs to a client. - Remain with the client for the first 15 min of infusion. 38. 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.” 39. 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 exhibited by the client - Widening pulse pressure - Decerebrate posturing 40. 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. - Remind the client to scan their complete range of vision during ambulation 41. A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit? - Heart rate 110/min 42. A nurse is 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? - Inject the medication into the anterolateral abdominal wall. 43. A nurse in a provider’s office is caring for a client who requests sildenafil to treat erectile dysfunction. Which of the following statements should the nurse make? - “You will not be able to use sildenafil if you are taking nitroglycerin.” 44. A nurse in an emergency department is assessing a client who has a detached retina. Which of the following should the nurse expect the client to report? - “It’s like a curtain closed over my eye.” 45. 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.” 46. 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 47. 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? - C (bottom left side) 48. 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.” 49. 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 is asking for a PRN sublingual nitroglycerin tablet. 50. A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pneumonia. Which of the following assessment findings is