Med Surg- Proctored ATI Exam
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 answer- 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
answer- 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 answer- "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 answer-
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 answer- 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
answer- 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 answer-
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 answer- 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 answer- 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
answer- 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 answer- 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 answer- 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 answer- 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.
A nurse is caring for a client who has a prescription for silver sulfadiazine cream to be
applied to her burn wounds. The nurse should evaluate the client for which of the
following laboratory findings? correct answer- Leukopenia
Transient leukopenia is an adverse effect of silver sulfadiazine.
A nurse is teaching a client with systemic erythematosus who has a new prescription for
prednisone. The nurse should instruct the client to monitor for which of the following
adverse effects of this medication? correct answer- Infection
The nurse should instruct the client to avoid contact with people who are ill and monitor
for manifestations of an infection such as a fever or a sore throat. Prednisone can
suppress the client's immune response and mask the manifestations of an infection.
A nurse is providing preoperative teaching to a client who will undergo a total
laryngectomy. Which of the following statements indicates that the client understands
the impact of the surgery? correct answer- "I understand that I will have a permanent
tracheostomy after the surgery."
With a partial laryngectomy, the tracheostomy is temporary. This client will have a total
laryngectomy, so the tracheostomy will be permanent.
A nurse is assessing a client who has systemic scleroderma. Which of the following
findings should the nurse expect? correct answer- Finger contractures
Scleroderma is a chronic disease that can cause thickening, hardening, or tightening of
the skin, blood vessels, and internal organs. There are 2 types of scleroderma: localized
scleroderma, which mainly affects the skin, and systemic scleroderma, which can affect
internal organs. Manifestations include skin changes, Raynaud's phenomenon, arthritis,
muscle weakness, and dry mucous membranes. With scleroderma the body produces
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 answer- 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
answer- 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 answer- "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 answer-
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 answer- 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
answer- 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 answer-
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 answer- 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 answer- 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
answer- 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 answer- 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 answer- 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 answer- 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.
A nurse is caring for a client who has a prescription for silver sulfadiazine cream to be
applied to her burn wounds. The nurse should evaluate the client for which of the
following laboratory findings? correct answer- Leukopenia
Transient leukopenia is an adverse effect of silver sulfadiazine.
A nurse is teaching a client with systemic erythematosus who has a new prescription for
prednisone. The nurse should instruct the client to monitor for which of the following
adverse effects of this medication? correct answer- Infection
The nurse should instruct the client to avoid contact with people who are ill and monitor
for manifestations of an infection such as a fever or a sore throat. Prednisone can
suppress the client's immune response and mask the manifestations of an infection.
A nurse is providing preoperative teaching to a client who will undergo a total
laryngectomy. Which of the following statements indicates that the client understands
the impact of the surgery? correct answer- "I understand that I will have a permanent
tracheostomy after the surgery."
With a partial laryngectomy, the tracheostomy is temporary. This client will have a total
laryngectomy, so the tracheostomy will be permanent.
A nurse is assessing a client who has systemic scleroderma. Which of the following
findings should the nurse expect? correct answer- Finger contractures
Scleroderma is a chronic disease that can cause thickening, hardening, or tightening of
the skin, blood vessels, and internal organs. There are 2 types of scleroderma: localized
scleroderma, which mainly affects the skin, and systemic scleroderma, which can affect
internal organs. Manifestations include skin changes, Raynaud's phenomenon, arthritis,
muscle weakness, and dry mucous membranes. With scleroderma the body produces
