Med surg- proctored ATI A+
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?
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?
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?
"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?
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?
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?
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?
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?
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).
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?
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?
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.)
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?
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?
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?
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?
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?
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?
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?
"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?
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?
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?
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?
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?
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).
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?
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?
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.)
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?
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?
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?
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?
