ATI MED SURGE
A nurse is caring for a client who is receiving chemotherapy and requests
information about acupuncture to relieve some of the side effects. which of
the following findings should the nurse identify as a contraindication to
receiving this alternative therapy?
Lymphedema
A nurse is preparing to administer lactated Ringer's via continuos IV
infusion at 200 ml/hr. The IV tubing has a drop factor of 10 drops/mL.
How many gtt/min should the nurse set the IV ump to administer?
33
A nurse is providing discharge teaching to a client who has a new prescription
for sublingual nitroglycerin. Which of the following client statements indicates
an understanding of the teaching?
I should lie down when I take this medication
A nurse is providing discharge teaching to an older adult client following total
hip arthroplasty. Which of the following instructions should the nurse include
in the teaching. Install a raised toilet seat in your bathroom
A nurse is planning care for a client following a cardiac catheterization.
which of the following actions should the nurse take.
Maintain the client's affected extremity in extension
A nurse is caring for a client who has a lower extremity fracture and a
prescription for crutches. which of the following client statements indicates
that the client is adapting to their role change?
I will need to have my partner take over shopping for groceries and cooking
the meals for us
A nurse is providing teaching to a client who has an impaired immune system
due to chemotherapy. which of the following information should the nurse
include in the teaching?
Change your pet's litter box daily
a nurse is caring for a client who has a contusion and reports thirst. The
client's urinary output was 4,000 ml over past 24 hr. the nurse should
anticipate a prescription for which of the following IV medications?
Desmopressin
A nurse in a clinic receives a phone call from a client who recently started
therapy with an ACE inhibitor and reports nagging dry cough. Which of the
following responses by the nurse is appropriate?
Sucking on a lozenge may reduce the frequency of your cough
,A nurse is taking an admission history from a client who reports
Raynaud's disease. Which of the following assessment findings should
the nurse identify as a parenteral trigger for exacerbation of Raynaud's?
Using nicotine transdermal patch
A nurse is caring for a client who has a central venous device and notes the
tubing has become disconnected. the client develops dyspnea and
tachycardia. Which of the following actions should the nurse take first?
...
A nurse is completing an assessment of an older client and notes reddened
areas over the bony prominences, but the client's skin is intact. which of the
following interventions should the nurse include in the plan of care?
Support bony prominences with pillows
A home health nurse is making an initial visit to a client who has multiple
sclerosis. Which of the following actions is the priority for the nurse to take?
...
A nurse in the emergency department is assessing a client. which of the
following actions should the nurse take first? (click on rhe "exhibit" button
for additional information about the client
Initiate airborne precautions
A nurse is reviewing the medical record of a client to identify factors
for colorectal cancer. The nurse should identify which of the following
findings as increasing the client's risk?
Historyof Crohn's disease
A nurse is caring for a client who is scheduled for a mastectomy. The client
tells the nurse, "I'm not sure I want to have a mastectomy." Which of the
following statements should the nurse make?
I can give you additional information about the
A nurse is preparing to administer a unit of packed RBCs to a client who is
anemic. Identify the sequence of steps the nurse should follow.
1. obtain venous access using a 19-gauge needle
2. Obtain the unit of a packed RBCs from
blood bank 3. verify blood compatibility with
another nurse
4. Initiate traensfuntion of the unit of packed
RBCs 5. Remain with the client for the first 15
to 30 minutes
A nurse is providing discharge teaching to a client following a modified
left radical mastectomy with breast expander. Which of the following
statements by the client indicates an understanding of the teaching.
I should expect less than 25 ml of secretions per day in the drainage devices
,A critical care nurse is assessing a client who has a severe head injury. In
response to painful stimuli, the client does not open her eyes, displays
decerebrate posturing and makes incomprehensible sounds. which of the
following glasgow Coma scale scores should the nurse assign the client?
5
A nurse is providing discharge teaching to a client who has heart failure and
instructs him to limit sodium intake to 2 g per day. Which of the following
statements by the client indicates an understanding of the teaching?
I can have a frozen fruit juice bar for dessert
A nurse is preparing to perform ocular irrigation for a client following a
chemical splash to the eye. Which of the following actions should the nurse
plan to take first?
Instill 0.9% sodium chloride solution into the affected eye
A nurse is assessing a client following extubation from a ventilator.for which
of the following findings should the nurse intervene immediately?
Stridor
A nurse is reviewing the laboratory reports of a client who has acute
pancreatitis. Which of the following findings should the nurse expect?
Elevated blood glucose
A nurse is reviewing the medical record of a client who has diabetes insipidus.
Which of the following findings should the nurse expect?
Urine specific gravity 1.001
A nurse is planning care for a client who has a pulmonary embolism. which of
the following interventions should the nurse include?
Initiate a continuos IV heparin infusion
a nurse is providing discharge teaching to a client who is recovering from a
sickle cell crisis. which of the following instructions should the nurse include?
Avoid extremely hot or cold temperatures
A nurse in the emergency department is caring for a client who is in
hypovolemic shock. Which of the following ac ons should the nurse take first?
Insert a large-bore IV catheter
A nurse is caring for a client who has an arteriovenous graft . Which of the
following findings indicates adequate circulation on of the graft?
Palpable thrill
A nurse is assessing a client who has heart failure and is receiving a loop
diure c. Which of the following nding indicates hypokalemia?
, Muscle weakness
A nurse is caring for a client in diabetic ketoacidosis (DKA) Which of the
following is the priority intervention by the nurse?
Infuse 0.9% normal saline
A nurse is providing discharge teaching to a client who has an ileostomy.
Which of the following client statements indicates an understanding of the
teaching?
I will expect my stools to be loss
A nurse is caring for a client who is receiving total parenteral nutri on through
a central line. The current bag is nearly empty, and a new bag is unavailable
from the pharmacy. Which of the following actions should the nurse take?
Switch the infusion to a 10% dextrose solution
A nurse is caring for a client who is 6hr postopera ve following a
thyroidectomy. The client reports tingling and numbness in the hands. The
nurse should identify this as a sign of which of the following electrolyte
imbalance?
Hypocalcemia
A nurse in a provider office is caring for a client who has total vision loss and
is the handler of a service dog. which of the following actions should the
nurse take to show consideration for the client and the service animal?
Consult the client before approaching the dog.
A nurse is reviewing medications taken at home with a client who has
angina. which of the following statements by the client indicates an
underestanding of the teaching?
I should lie down before taking a dose of isosorbide dinitrate
A nurse in the post anesthesia care unit is assessing a client following an
appendectomy and finds a 2 cm (3/4 in) area of blood on the postoperative
dressing. which of the following actions should the nurse take?
Apply pressure
A nurse is caring for a client who is receiving mechanical ventilation. which
of the following interventions should the nurse implement?
...
A nurse is planning care for a client who has full-thickness burns on the
lower extremities. Which of the following interventions should the nurse
include?
Apply new gloves when alternating between wound care sites.
A nurse is providing teaching for a client who has tuberculosis and a new
prescription for pyrazinamide. The nurse should instruct the client to
notify the provider if which of the following adverse effects occurs?
Jaundice
A nurse is caring for a client who is receiving chemotherapy and requests
information about acupuncture to relieve some of the side effects. which of
the following findings should the nurse identify as a contraindication to
receiving this alternative therapy?
Lymphedema
A nurse is preparing to administer lactated Ringer's via continuos IV
infusion at 200 ml/hr. The IV tubing has a drop factor of 10 drops/mL.
How many gtt/min should the nurse set the IV ump to administer?
33
A nurse is providing discharge teaching to a client who has a new prescription
for sublingual nitroglycerin. Which of the following client statements indicates
an understanding of the teaching?
I should lie down when I take this medication
A nurse is providing discharge teaching to an older adult client following total
hip arthroplasty. Which of the following instructions should the nurse include
in the teaching. Install a raised toilet seat in your bathroom
A nurse is planning care for a client following a cardiac catheterization.
which of the following actions should the nurse take.
Maintain the client's affected extremity in extension
A nurse is caring for a client who has a lower extremity fracture and a
prescription for crutches. which of the following client statements indicates
that the client is adapting to their role change?
I will need to have my partner take over shopping for groceries and cooking
the meals for us
A nurse is providing teaching to a client who has an impaired immune system
due to chemotherapy. which of the following information should the nurse
include in the teaching?
Change your pet's litter box daily
a nurse is caring for a client who has a contusion and reports thirst. The
client's urinary output was 4,000 ml over past 24 hr. the nurse should
anticipate a prescription for which of the following IV medications?
Desmopressin
A nurse in a clinic receives a phone call from a client who recently started
therapy with an ACE inhibitor and reports nagging dry cough. Which of the
following responses by the nurse is appropriate?
Sucking on a lozenge may reduce the frequency of your cough
,A nurse is taking an admission history from a client who reports
Raynaud's disease. Which of the following assessment findings should
the nurse identify as a parenteral trigger for exacerbation of Raynaud's?
Using nicotine transdermal patch
A nurse is caring for a client who has a central venous device and notes the
tubing has become disconnected. the client develops dyspnea and
tachycardia. Which of the following actions should the nurse take first?
...
A nurse is completing an assessment of an older client and notes reddened
areas over the bony prominences, but the client's skin is intact. which of the
following interventions should the nurse include in the plan of care?
Support bony prominences with pillows
A home health nurse is making an initial visit to a client who has multiple
sclerosis. Which of the following actions is the priority for the nurse to take?
...
A nurse in the emergency department is assessing a client. which of the
following actions should the nurse take first? (click on rhe "exhibit" button
for additional information about the client
Initiate airborne precautions
A nurse is reviewing the medical record of a client to identify factors
for colorectal cancer. The nurse should identify which of the following
findings as increasing the client's risk?
Historyof Crohn's disease
A nurse is caring for a client who is scheduled for a mastectomy. The client
tells the nurse, "I'm not sure I want to have a mastectomy." Which of the
following statements should the nurse make?
I can give you additional information about the
A nurse is preparing to administer a unit of packed RBCs to a client who is
anemic. Identify the sequence of steps the nurse should follow.
1. obtain venous access using a 19-gauge needle
2. Obtain the unit of a packed RBCs from
blood bank 3. verify blood compatibility with
another nurse
4. Initiate traensfuntion of the unit of packed
RBCs 5. Remain with the client for the first 15
to 30 minutes
A nurse is providing discharge teaching to a client following a modified
left radical mastectomy with breast expander. Which of the following
statements by the client indicates an understanding of the teaching.
I should expect less than 25 ml of secretions per day in the drainage devices
,A critical care nurse is assessing a client who has a severe head injury. In
response to painful stimuli, the client does not open her eyes, displays
decerebrate posturing and makes incomprehensible sounds. which of the
following glasgow Coma scale scores should the nurse assign the client?
5
A nurse is providing discharge teaching to a client who has heart failure and
instructs him to limit sodium intake to 2 g per day. Which of the following
statements by the client indicates an understanding of the teaching?
I can have a frozen fruit juice bar for dessert
A nurse is preparing to perform ocular irrigation for a client following a
chemical splash to the eye. Which of the following actions should the nurse
plan to take first?
Instill 0.9% sodium chloride solution into the affected eye
A nurse is assessing a client following extubation from a ventilator.for which
of the following findings should the nurse intervene immediately?
Stridor
A nurse is reviewing the laboratory reports of a client who has acute
pancreatitis. Which of the following findings should the nurse expect?
Elevated blood glucose
A nurse is reviewing the medical record of a client who has diabetes insipidus.
Which of the following findings should the nurse expect?
Urine specific gravity 1.001
A nurse is planning care for a client who has a pulmonary embolism. which of
the following interventions should the nurse include?
Initiate a continuos IV heparin infusion
a nurse is providing discharge teaching to a client who is recovering from a
sickle cell crisis. which of the following instructions should the nurse include?
Avoid extremely hot or cold temperatures
A nurse in the emergency department is caring for a client who is in
hypovolemic shock. Which of the following ac ons should the nurse take first?
Insert a large-bore IV catheter
A nurse is caring for a client who has an arteriovenous graft . Which of the
following findings indicates adequate circulation on of the graft?
Palpable thrill
A nurse is assessing a client who has heart failure and is receiving a loop
diure c. Which of the following nding indicates hypokalemia?
, Muscle weakness
A nurse is caring for a client in diabetic ketoacidosis (DKA) Which of the
following is the priority intervention by the nurse?
Infuse 0.9% normal saline
A nurse is providing discharge teaching to a client who has an ileostomy.
Which of the following client statements indicates an understanding of the
teaching?
I will expect my stools to be loss
A nurse is caring for a client who is receiving total parenteral nutri on through
a central line. The current bag is nearly empty, and a new bag is unavailable
from the pharmacy. Which of the following actions should the nurse take?
Switch the infusion to a 10% dextrose solution
A nurse is caring for a client who is 6hr postopera ve following a
thyroidectomy. The client reports tingling and numbness in the hands. The
nurse should identify this as a sign of which of the following electrolyte
imbalance?
Hypocalcemia
A nurse in a provider office is caring for a client who has total vision loss and
is the handler of a service dog. which of the following actions should the
nurse take to show consideration for the client and the service animal?
Consult the client before approaching the dog.
A nurse is reviewing medications taken at home with a client who has
angina. which of the following statements by the client indicates an
underestanding of the teaching?
I should lie down before taking a dose of isosorbide dinitrate
A nurse in the post anesthesia care unit is assessing a client following an
appendectomy and finds a 2 cm (3/4 in) area of blood on the postoperative
dressing. which of the following actions should the nurse take?
Apply pressure
A nurse is caring for a client who is receiving mechanical ventilation. which
of the following interventions should the nurse implement?
...
A nurse is planning care for a client who has full-thickness burns on the
lower extremities. Which of the following interventions should the nurse
include?
Apply new gloves when alternating between wound care sites.
A nurse is providing teaching for a client who has tuberculosis and a new
prescription for pyrazinamide. The nurse should instruct the client to
notify the provider if which of the following adverse effects occurs?
Jaundice
