ATI Medical Surgical Exam Q&A Review with rationales

ATI Med-Surg (Multiple Response) 1. 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 INCORRECT 5) Bradycardia Answer Rationale: Dyspnea is correct. Dyspnea is experienced by clients who have emphysema due to inadequate oxygen exchange in the lungs. Barrel chest is correct. The lungs of clients who have emphysema lose their elasticity, and the diaphragm becomes permanently flattened by overdistention of the lungs. The muscles of the rib cage also become rigid, and the ribs flare outward. This produces the barrel chest typical of emphysema clients. Clubbing of the fingers is correct. Air is trapped in the lungs due to their lack of elasticity, which decreases oxygenation. Clubbing results from these chronic low blood-oxygen levels. Shallow respirations is correct. Clients who have emphysema lose lung elasticity; consequently, respirations become increasingly shallow and more rapid. Bradycardia is incorrect. The heart rate will increase as the heart tries to compensate for less oxygen being delivered to the tissues. 2. 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 INCORRECT 4) Tremors INCORRECT 5) Obese extremities Answer Rationale: Buffalo hump is correct. Cushing's syndrome is a disease caused by an increased production of cortisol or by excessive use of corticosteroids. Buffalo hump, a collection of fat between the shoulders, is a common manifestation of Cushing's syndrome.Purple striations is correct. Purple striations on the skin of the abdomen, thighs, and breasts are a common manifestation of Cushing's syndrome. This is due to the collection of body fat in these areas.Moon face is correct. Moon face is a common manifestation of Cushing's syndrome. Clients who have this manifestation present with a round, red, full face.Tremors is incorrect. Tremors are not a common finding of Cushing's syndrome.Obese extremities is incorrect. Clients who have Cushing's syndrome have truncal obesity, a protuberant abdomen, with thin extremities, which is due to an alteration in protein metabolism. 3. 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. INCORRECT 3) Insert a urinary catheter. INCORRECT 4) Elevate the client’s head of bed. INCORRECT 5) Apply a cervical collar to the client. Answer Rationale: Encourage fluid intake is correct. The nurse should encourage fluids, unless contraindicated, to replace the cerebrospinal fluid that was removed during the procedure and reduce the risk for a headache. Monitor the puncture site for a hematoma is correct. The nurse should monitor and report a hematoma at the insertion site because this can indicate bleeding. Insert a urinary catheter is incorrect. There is no indication for a urinary catheter insertion. Elevate the client’s head of bed is incorrect. The client should remain flat in bed for 1 hr or more to reduce the risk for a headache. Apply a cervical collar to the client is incorrect. There is no indication for a cervical collar for this client. 4. A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is to take hydroxyzine preoperatively. Which of the following effects of the medication should the nurse include in the teaching? (Select all that apply.) 1) Decreasing anxiety 2) Controlling emesis INCORRECT 3) Relaxing skeletal muscles INCORRECT 4) Preventing surgical site infections 5) Reducing the amount of narcotics needed for pain relief Answer Rationale: Decreasing anxiety is correct. The nurse should include that hydroxyzine is an effective antianxiety agent and is used to decrease anxiety in surgical clients as well as in persons with moderate anxiety. Controlling emesis is correct. The nurse should include that hydroxyzine is an effective antiemetic and is used to control nausea and vomiting in pre- and postoperative clients. Relaxing skeletal muscles is incorrect. The nurse should recognize benzodiazepines, such as diazepam (Valium), are used to produce skeletal muscle relaxation. Preventing surgical site infections is incorrect. The nurse should instruct the client that antibiotics administered prior to surgery are used to diminish the risk of surgical site infections; hydroxyzine, an antiemetic, does not have any effect on bacteria. Reducing the amount of narcotics needed for pain relief is correct. Hydroxyzine increases the effects of narcotic pain medications. The nurse should instruct the client that when it is used for surgical clients, narcotic requirements may be significantly reduced. 5. A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The nurse determines that teaching has been effective when the client identifies which of the following manifestations of hypoglycemia? (Select all that apply.) INCORRECT 1) Polyuria 2) Blurry vision 3) Tachycardia INCORRECT 4) Polydipsia 5) Sweating Answer Rationale: Polyuria is incorrect. Hyperglycemia causes polyuria. Blurry vision is correct. Manifestations of hypoglycemia include blurry vision, tremors, anxiety, irritability, headache, and hypotension. Tachycardia is correct. Manifestations of hypoglycemia include tachycardia, tremors, anxiety, irritability, headache, and hypotension. Polydipsia is incorrect. Hyperglycemia causes polydipsia. Sweating is correct. Manifestations of hypoglycemia include sweating, tremors, anxiety, irritability, headache, and hypotension. 6. A nurse is collecting data from a client who has an exacerbation of gout. Which of the following findings should the nurse expect? (Select all that apply.) 1) Edema 2) Erythema 3) Tophi 4) Tight skin INCORRECT 5) Symmetrical joint pain Answer Rationale: Edema is correct. Swelling over the affected joints is a classic manifestation of gout. Erythema is correct. Redness over the affected joints is a classic manifestation of gout. Tophi is correct. Tophi are a classic manifestation of gout. They are nodules that form in subcutaneous tissue due to the accumulation of urate crystals. Tight skin is correct. Tight skin over the affected joints is a classic manifestation of gout. Symmetrical joint pain is incorrect. Symmetrical joint pain is a manifestation of rheumatoid arthritis, not gout. 7. A nurse is assisting in the plan of care for a client who had surgery for a bowel obstruction. The client has a nasogastric tube in place. Which of the following actions should the nurse include in the client's plan of care? (Select all that apply.) 1) Perform leg exercises every 2 hr. 2) Encourage hourly use of an incentive spirometer while awake. 3) Document the color, consistency, and amount of nasogastric drainage. INCORRECT 4) Irrigate the nasogastric tube every 4 to 8 hr. INCORRECT 5) Maintain bed rest for 48 hr following surgery. Answer Rationale: Perform leg exercises every 2 hr is correct. Postoperative clients should frequently perform leg exercises, independently or with assistance, to prevent skin breakdown.Encourage hourly use of an incentive spirometer while awake is correct. Postoperative clients should be encouraged to use the incentive spirometer ten times each hour while awake to prevent atelectasis.Document the color, consistency, and amount of nasogastric drainage is correct. Documenting the color, consistency, and amount of nasogastric drainage is appropriate to include in the client's plan of care.Irrigate the nasogastric tube every 4 to 8 hr is incorrect. Following abdominal surgery, the NG tube should not be moved or irrigated unless prescribed by the provider.Maintain bed rest for 48 hr following surgery is incorrect. Maintaining bed rest following surgery should not be included in the plan of care. Early ambulation prevents distention and improves intestinal mobility. 8. A nurse is assisting with discharge teaching for a client who is postoperative following a laryngectomy. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) 1) To aid in swallowing food, tip the chin before swallowing. INCORRECT 2) Avoid using liquid supplements. INCORRECT 3) Include warm foods in your diet because they are easier to swallow. 4) Swallow twice after each bite. INCORRECT 5) Take a sip of water with each bite of food. Answer Rationale: To