ATI MED SURG Proctored Actual EXAM Questions AND Correct Detailed Answers100%

lOMoARcPSD| ATI MED SURG Proctored Actual EXAM Questions AND Correct Detailed Answers (VerifiedAnswers)LatestUpdates lOMoARcPSD| ATI MED SURG PROCTORED ACTUAL EXAM QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIEDANSWERS) LATEST UPDATES GUARANTEED PASS A+ A nurse is caring for a client who experience datraumatic head injury and has an intraventricular catheter (Ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy?: a.Headache b.Infection c.Aphasia d. Hypertension (Correct Answer)−b. Infection Monitor for infection and use strict asepsis to avoid life−threatening meningitis. A nurse is providing education to a client who is to under gown EEG the next day. Which of the following in of should the nurse include in the teaching? a. "Do not wash your hair the morning of the procedure." b. "Try and stay awake most of the night prior to the procedure." c. "The procedure will take approximately 15mins." d. "You will need to lie flat for 4 hours after the procedure. "(Correct Answer)−b."Try and stay awake most of the night prior to the procedure." Tell the client to remain awake to provide cranial stress and increase the possibility of abnormal electrical activity A nurse is caring for a client who is post procedural following a lumb a puncture and report sat robbing headache when sitting upright. Which of the following actions should the nurse take? SATA. lOMoARcPSD| a.Use the GCS scale to assess the client b. Assist the client into a supine position c.Administer an opioidanalgesic d. En-courage the client to increase Po fluid in take e.Instruct the client to perform coughing and deep breathing (Correct Answer)−B,D A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following findings should the nurse report to the provider? A Output equal to the instilled irrigate b.Client reports bladder spasms c.Viscous urinary output with clots d.Reports of strong urgetourinate (Correct Answer)−c. Viscous urinary output with clots Urine that is bright red with clots is an indication of arterial bleeding. A nurse is monitoring the ECG of a client who has hypocalcaemia. Which of the following findings should the nurse expect? a.Flattened T waves b. Prolonged QT intervals c.Shortened QT intervals D. Widened QRS complexes lOMoARcPSD| (Correct Answer)−b. Prolonged QT intervals Manifestations of hypocalcaemia include tingling, numbness, tetany, seizures, prolonged QT intervals, and laryngospasm. lOMoARcPSD| A nurse is preparing a client who has a brain tumor for a CT scan. Which of the following factors affects the manner in which the nurse will prepare the client for the scan? a.No foodorfluidsconsumedfor4hours b. Difficult rye calling recent events c.Development of hives while eating shrimp. d.Parenthesis in both hands (Correct Answer)−c .Development of hives while eating shrimp Shell fish allergy is contraindication of use of contrast media during a CT scan. A nurse is preparing an in− service program about the stages of acute kidney injury. Which of the following pieces of in for should the nurse include about prerenalazotemia? a.Pre renal azotemia begin sprier to the on set of symptoms b.Interference with renal perfusion causes renal azotemia c.Pre renal azotemia is irreversible, even in early stages d.Infections and tumors cause pre renal azotemia (Correct Answer)−b. Interference with renal perfusion causes pre renal azotemia. Pre renal interference with re nalperfusion, such as from heart failure or hypovolemic shock. A nurse is teaching a client who has CAD about the difference between angina pectoris and MI. Which of the following should the nurse identify as indications of MI? SATA. a.N/V b. Diaphoresis and dizziness c.Chest and left arm pain that subsides with rest d. Anxiety and feeling sofdoom lOMoARcPSD| e.Bounding pulse and bradypnea (Correct Answer)−A,B,D A nurse is reviewing the lab results of a lump a puncture for a client who has manifestations of bacterial meningitis. Which of the following findings should the nurse expect? a.Elevated glucose b. Elevated protein c.Presence of RBCs d. Presence of D−dimer (Correct Answer)− b. Elevated protein Manifestations of bacterial meningitis include increase protein in the CSF, decreased glucose. RBC scan indicate bleeding, however, WBCs are what indicates bacterial meningitis. A nurse is providing teaching to a client who has an ewdiagnos is of myasthenia gravis(MG). Which of the following pieces of information should the nurse include? A.Use enemastotreat constipation caused by daily medications B.Take a hot bath when muscles ache C.Eat a low – calorie diet D.Set an alarm to ensure medication dosages are taken on time (Correct Answer)− D. Set an alarm to ensure medication dosages are taken on time The nurse should instruct the client to take medication dosages on time to maintain a therapeutic blood level . Dosages should not be missed or postponed because this can cause an exacerbation of the disease. A nurse is teaching a client who has an ewdiagnos is of primary open−angle glaucoma(POAG). Which of the following pieces of information should the nurse include in the teaching? (Select lOMoARcPSD| all that apply.) lOMoARcPSD| A.Lost vision can improve with eye drops. B.Administer eye drops as needed for vision loss. C.Glasses will be necessary to correct the accompanying pres by opia. D.Driving can be dangerous due to the loss of peripheral vision. E.Laser surgery can help reestablish the flow of aqueous humor. (Correct Answer)− D. Driving can be dangerous due to the loss of peripheral vision. A nurse is assessing a client who has a fractured left femur and is in skeletal traction. Which of the following findings should the nurse report to the provider? A. Ecchymosed of the thigh B. Serous drain age at the pin site C. Chest petechiae D. Muscle spasms in the left leg (Correct Answer)− C.Chest petechiae The nurse should identify chest petechiae as an indication of fat emboli smsyndrome. Clients who have fractures of the long bones such as the femur are at increased risk of fat emboli. Fat emboli typically occur 12 to 48 hours after the injury when fat droplets from the marrowenterinto the systemic circulation and are deposited in the lungs. The nurse should immediately notify the provider because the client could progress to acute respiratory failure. A nurse is assessing a client who has Kaposi's sarcoma. Which of the following findings should the nurse expect? A. Non productive cough, fever, and shortness of breath lOMoARcPSD| B. Lesion son the retina that produce blurred vision C. On set of progressive dementia D. Reddish –purple skin lesions (Correct Answer)− D .Reddish−purple skin lesions Kaposi's sarcoma is commonly associated with AID Sand manifests as hyper pigmented multi centric lesions that can be firm, flat, raised, or nodular. Following a biopsy, the lesions are treated with radiation and/ or chemo therapy. A nurse is completing an assessment for a client who has a history of unstable angina. Which of the following findings should the nurse expect? A. Chest pain is relieved soon after resting. B. Nitroglycerin relieves chest pain. C. Physical exertion does not precipitate chest pain. D. Chest pain lasts for longer than 15 min .(Correct Answer)− D.Chest pain lasts for longer than 15 min. A client who has unstable angina will have chest pain lasting longer than 15 minutes. This is due to reduced blood flow in a coronary artery from atherosclerotic plaque and thrombus formation causing partial arterial obstruction or from an artery spasm. .A client who has unstable angina will have chest pain even while resting because of insufficient blood flow to the coronary arteriesanda decreased oxygen supply. Chest pain Artesia condition called variant (Prinzmetal's) anginaandis caused by an arterial spasm. B.A client who has unstable angina will have minimal, if any, relief of chest pain with nitroglycerin. lOMoARcPSD| C. A client who has unstable Angina will report chest pain or discomfort with exertion, which can limit the client's activity. A nurse is assessing a client with a closed head injury who has received Manito foraminifer stations of increased intra cranial pressure(ICP).Which of the following findings indicates that the medication is having a therapeutic effect? A. The client's serum osmolarity is 310mOsm/L. B. The client's pupils are dilated. C.Theclient'sheartrateis56/min. D. The client is restless. (Correct Answer)− A.The client's serumosmolarity is 310mOsm/L. Mannitolisanosmoticdiureticusedtoreducecerebraledemabydrawingwateroutofthebraintissue.Ase rumosmolarityof 310mOsm/ Lisdesired. A decrease incerebraledema should result in a decrease in ICP. A nurse is planning care for a client who has AID Sand has developed steatites. Which of the following interventions should the nurse include in the plan of care? A. Rinse the mouth with chlorhexidine solution every 2hr B. Limit fluid in take with meals C. Provide oral hygiene with a firm−bristled tooth brush after each meal D .Avoid salty foods (Correct Answer)− D. Avoid salty foods Stomatitis is an inflammation of the mucosa of the mouth, usually with ulcerations. Foods that are spicy, acidic, or salty should be avoid edto prevent further irritation and damage to the oral mucosa. lOMoARcPSD| A nurse is caring for a client who had a left lower lobotomy to treat lung cancer. Which of the following factors will have a significant impact on the plan of care for this client? A. The client will need intensive smoking− cessation education. B. After surgery, the prognosis for clients with lung cancer is usually good. C. Lung cancer usually has metastasized before the client presents with symptoms. D. Oxygen therapy is in effective following a lobectomy . (Correct Answer)− C. Lung cancer usually has metastasized before the client presents with symptoms. The nurse should be aware that lung cancer is usually at an advanced stage before the client has any manifestations. This has implications for both short –term and long – term care options for the client. A nurse is examining the ECG of a client who has hyperkalemia. Which of the following ECG changes should the nurse expect? A. Elevated ST segments B. Absent P waves C. Depressed ST segments D. Varying PP intervals (Correct Answer)− A. Elevated ST segments Elevated ST segments can indicate hyperkalemia and pericarditis. A nurse is caring for a client during the first 72 hr following a cerebra vascular accident(CVA). Which of the following actions should the nurse take? A. Turn the client's head to the side with the head of the bed elevated 60˚ lOMoARcPSD| B. Place the head of the bed flat with pillows under the client's neck and feet lOMoARcPSD| C. Elevate the head of the bed 25˚to 30˚with the client in a neutral midline position D. Position the client in a dorsal recumbent position with pillows under the head and knees (Correct Answer)− All options A nurse is caring for a client who is taking streptomycin. Which of the following medications increases the client's risk of developing to toxicity when taken with streptomycin? A. Cefoxitin B. Furosemide C. Naproxen D. Amphotericin B (Correct Answer)− B. Furosemide Furosemide, ahigh –ceiling (loop) diuretic, increases the risk of developing to toxicity when taken with streptomycin, anaminoglyco side. A nurse is preparing to administer an IM injection for a client. Which of the following factors should the nurse identify as a potential contraindication to administering the medication via the IM route? A. The medication is a depot preparation. B. The client is taking an anticoagulant. C. The medication is a particulate suspension. D. The client has been vomiting. (Correct Answer)− B. The client is taking an anticoagulant. Because of the risk of bleeding from the injection site, anticoagulant therapy (e.g. warfarin) is a contraindication to receiving medications via the IM route. A nurse is caring for a client with Clostridium difficile who has contact – isolation precautions lOMoARcPSD| in place. Which of the following actions should the nurse perform? lOMoARcPSD| A. Instruct visitors to maintain a distance of at least 1m (3ft) from the client B. Wash hands with antimicrobial soap after leaving the client's room. C. Use dedicated equipment for the client. D. Keep the doors to the client's room closed at all times. (Correct Answer)− C. Use dedicated equipment for the client. The nurse should use dedicated equipment that is left in the room for a client who has contact – isolation precautions in place. A nurse is assessing a client who sustained superficial partial− thickness and deep partial – thickness burns 72 hr ago . Which of the following findings should the nurse report to the provider? A. Edema in the burned extremities B. Severe pain at the burn sites C. Urine out put of 30m L/hr D. Temperature of 39.1˚C (102.4˚F) (Correct Answer)− D. Temperature of 39.1˚C (102.4˚F) An elevated temperature is an indication of infection , and the nurse should report this finding to the provider. Sepsis is a critical finding following a major burn injury. Initially, burn wounds are relatively lOMoARcPSD| Pathogen –free . On approximately the third day following the injury, early colonization of the wound surface by gram− negative organisms changes to predominantly gram− positive opportunistic organisms. An emergency room nurse is assessing a client who has anew traumatic brain injury. The nurse observes extension of the client's arm sand legs, pro nation of the arms, and plantar flexion of the feet. Which of the following actions is the nurse's priority? A. Monitor urinary output B. Administer an osmotic diuretic C. Provide supplemental oxygen D. Initiate seizure pre cautions (Correct Answer)− C .Provide supplemental oxygen The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to provide supplemental oxygen. The client might require an artificial airway and mechanical ventilation because these findings indicated e cerebrate positioning, which is associated with brainstem injury and can lead to brain hernia ion and death. A nurse is teaching a client who has persistent cancer pain about the adverse effects of opioids .Which of the following statements should the nurse include in the teaching? A. "Opioids do not relieve pain without causing severe adverse effects." B."Physical dependence is not the same as addiction." C."Tolerance typically means that the medication will no longer be effective." D." The most common adverse effect is respiratory depression with prolonged use. "(Correct Answer)− B. "Physical dependence is not the same as addiction." The nurse should explain that physical dependence can occur in all clients who take opioids, and the client may develop abstinence syndrome if the opioidis abruptly with drawn. Physical dependence is not the same as addiction, but it can result in addiction . Addiction results when the opioidis continued despite physical or psychological harm. lOMoARcPSD| A nurse is preparing a client who is scheduled to have an arthroscopy the following day. Which of the following statements indicates that the client understands the pre −procedure teaching? A. "I have toke epmy leg straight through out the whole procedure." B."The doctor will be able to see if I have signs of rheumatoid arthritis." C."I should expect to stay overnight until can walk around." D."I 'll have a scar that will be about an inch long. "(Correct Answer)− B."The doctor will be able to see if I have signs of rheumatoid arthritis." An arthroscopy helps with diagnosing muscle skeletal disorders such as rheumatoid arthritis, osteoarthritis, and internal joint injuries. A nurse is caring for a client who has manifestation so acute tubular necrosis(ATN) following a kidney transplantation .Which of the following interventions should the nurse anticipate for this client? (Select all that apply.) A. Hem dialysis B.Biopsy C. Immunosuppressant D.Balloon angioplasty E.Surgical repair (Correct Answer)− A,B,C Clients who develop ATN after transplantation surgery might need dialysis until they have an adequate urine output and their BUN and cretin in levels stabilize. Because the development of ATN after transplantation surgery mimics the symptoms of rejection of the transplanted kidney, clients have to under go biopsy to determine the correct diagnosis. Immune suppressive medication therapy is essential after kidney transplantation to protect the new kidney. lOMoARcPSD| A nurse is providing teaching to a client who is scheduled for a sigmoid colon resection with colostomy. Which of the following statements by the client indicates a need for further teaching? A. "Because most of my colon is still intact and functioning, my stool will be formed." B."My stoma will appear large at first , but it will shrink over the next several weeks." C."My colostomy will begin to function in 2 to 6 days after surgery." D."I 'll have to consume a soft diet after surgery. E. "(Correct Answer)− D."I' ll have to consume a soft diet after surgery." The nurse should identify that this statement requires further teaching. After surgery, the client quickly returns to a regular diet ,and there are no food restrictions unless the client chooses to decrease the intake of foods that increase gas or odor. A nurse is caring for a client who is 2 days postoperative. Which of the following findings indicates that the client is developing an infection? A.Temperature 37.8˚C(100˚F) B. Erythematic the incision site C.WBC count 9,000/mm^3 D.Pain reported as 6 on a scale of 0 to 10 (Correct Answer)− B. Erythematic the incision site Redness at the incision site is an initial sign of a wound infection and requires intervention by the nurse. A nurse is caring for a client who had a cereb rovascular accident (CVA). The client appear salertand engaged during a visit but does not respond verbally to questions. The nurse should document this as which of the followingalterations? lOMoARcPSD| A.Expressive aphasia B.Dysarthria C.Receptive aphasia D.Dysphasia (Correct Answer)− A. Expressive aphasia A client who has expressive aphasia understands speech but has difficulty speaking and writing. This typically occurs as a result of a lesion at Broca's area of the frontal lobe. A nurse is teaching a female client with an ewdiagnosis of systemiclupuserythematosus (SLE) about factors that can trigger an exacerbation of SLE. The nurse should determine that the client requires further teaching if she identifies which of the following as an exacerbation factor? A.Exercise B.Pregnancy C.Infection D.Sunlight (Correct Answer)− A. Exercise SLE is a chronic to immured is ease that develops when the immune system becomes hyperactive and attacks healthy body tissue. This attack results in generalized inflammation and creates man if estuations associated with the specific involved tissues. Most clients who have SLE can follow an exercise program to increase their cellular aerobic capacity and improve immune function, and the client should follow a program with her provider's assistance. This client needs additional teaching about the importance of exercise to keep her muscles and joints active. A nurse is caring for a client who has type 1 diabetes mellitus and a capillary blood glucose reading of 48mg/dL. Which of the following findings should the nurse expect? lOMoARcPSD| A.Kussmaul respirations B.Diaphoresis C.Decreased skin turgor lOMoARcPSD| D.Ketonuria (Correct Answer)− B. Diaphoresis A client who has a blood glucose level below 70mg/dL will exhibit man if estuations of hypoglycemia. Expected findings associated with hypoglycemia include weakness, hunger, diaphoresis, nausea, shakiness, and confusion. A nurse is caring for a client who has a major burn injury and is experiencing third spacing. Which of the following fluid or electrolytic balances should the nurse expect? A.Hypokalemia B.Hypernatremia C.Elevated Hct D.Decreased Hgb (Correct Answer)− C. Elevated Hct The nurse should expect a client who is experiencing third spacing resulting from a major burn to have an elevated hematocrit level as blood volume is reduced by vascular hydration. A nurse is examining the ECG of a client who has frequent premature ventricular contractions(PVCs). Which of the following QRS changes should the nurse expect to see on the client's ECG? A. Narrower than usual QRS complexes B. Much greater amplitude than the usual QRS complexes C. Same polarity as the usual QRS complexes D. Immediate resumption of the usual rhythm lOMoARcPSD| (Correct Answer)− B. Much greater amplitude than the usual QRS complexes The QRS complexes unusually have greater amplitude in height and depth in clients with PVCs. A nurse is caring for a client who is experiencing autonomic dysreflexiaduetoaC5 spinal cord injury. After checking the client's vital signs, which of the following actions should the nurse perform next? A. Administer nifedipine B. Place the client in a high−Fowler's position C. Check for urinary retention D. Check for a fecal impaction (Correct Answer)− B. Place the client in a high−Fowler's position According to evidence− based practice, the nurse should first place the client in a high− Fowler's position to decrease the client's blood pressure and reduce the risk of end− organ damage from the sudden rise in blood pressure. A nurse is monitoring a client for reperfusion following thrombolytic therapy to treat acute myocardial infarction(MI) . Which of the following indicators should the nurse identify to confirm reperfusion? A. Ventricular dysrhythmias B. Appearance of Q waves C. Elevated ST segments D. Recurrence of chest pain (Correct Answer)− A. Ventricular dysrhythmias lOMoARcPSD| The appearance of ventricular dysrhythmias following thrombolytic therapy Is a sign of reperfusion of the coronary artery. A nurse is teaching a newly licensed nurse about caring for a client who is scheduled for an esophagogastric balloon tamponade tube to treat bleeding esophageal avarices. Which of the following pieces of information should the nurse include in the teaching? A. The client will be placed on mechanical ventilation prior to this procedure. B. The tube will be inserted in to the client's trachea. C. The client will receive a bowel preparation with cathartics prior to this procedure. D. The tube allows the application of a ligation band to the bleeding varices. (Correct Answer)− A. The client will be placed on mechanical ventilation prior to this procedure The client will require in tubation and mechanical ventilation prior to this procedure to protect the airway. A nurse is preparing an in−service presentation about the management of myocardial infarction(MI). Death following MI is often a result of which of the following complications? A. Cardiogenic shock B. Dysrhythmias C. Heart failure D. Pulmonary edema (Correct Answer)− B. Dysrhythmias According to evidence−based practice, dysrhythmias (specifically ventricular fibrillation) are lOMoARcPSD| the most common cause of death following MI. Therefore, nurses should monitor clients' ECGs carefully for dysrhythmias and report and treat them immediately. Anurseisteachingaclientwhohaspolycythemiaveraaboutself−caremeasures.Whichofthefollowin ginterventionsshouldthenurseinclude? A."Drink at least 1 liter of fluid each day." B." Continuously wear support hose." C. "Elevate your legs when sitting." D." Use dental floss daily. "(Correct Answer)− C." Elevate your legs when sitting." Clients who have polycythemiavera should elevate their legs when seated to avoid venous pooling with subsequent clot formation. A nurse is planning care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan of care? A. Restrict fluids to 1,000mL per day B. Measure the client's abdominal girth daily C. Check IV sites every 4hr for bleeding D.Administer an enemas needed for constipation (Correct Answer)− B. Measure the client's abdominal girth daily The nurse should measure the client's abdominal girth daily to monitor for man if estation so internals bleeding. A client who has a reduced plateletcountisat risk of bleeding due to delayed clotting. lOMoARcPSD| A nurse is assessing for disseminated intravascular coagulation(DIC) in a client who has septic shock secondary to an untreated foot wound. Which of the following findings should the nurse expect? (Select all that apply.) A. Bradycardia B. Bleeding at thevenipuncture site C. Petechiae on the chest and arms D. Flushed, dry skin E. Abdominal distension (Correct Answer)− BCE The formation of large amounts of micro emboli in the circulation depletes the body's platelet sand clotting factors. As a result, un controllable bleeding can occur, as manifested by bleeding at the venipuncturesite, petechiae on the chest and arms, and bleeding in the abdominal cavity resulting in abdominal distensiondueto internal bleeding. A nurse is caring for a semiconscious client who had a small−bore NG tube placed yesterday for the administration of entreat feeding. Which of the following methods should the nurse use to verify correct tube placement? (Select all that apply.) A. A uscultateinjectedair B. Verify the initial X−ray examination C. Measure the length of the exposed tube D. Determine the pH of aspirated fluid E. Check the aspirated fluid for glucose (Correct Answer)− B. Verify the initial X−ray examination lOMoARcPSD| A nurse is teaching a client who is postoperative how to use a flow−oriented incentives pyrometer. Which of the following instructions should the nurse include? A. Blow into the spirometer to elevate the balls in the device B. Cough deeply after each use C. Clean the mouth piece with an alcohol swab after each use D.Use the spirometer every 8hr (Correct Answer)− B. Cough deeply after each use Proper use of the incentive spirometer loosens secretions in the client's lungs .The client should cough deeply to facilitate the removal of secretions from his lungs. A. The nurse should instruct the client to in hale deeply to elevate the balls in the device. B. The nurse should instruct the client to clean the mouthpiece with water and dry it after each use. C. The nurse should instruct the client to use the spirometer several times every hour while awake. A nurse is talking with a group of women at a community center about the current recommendations for early detection of breast cancer. The nurse should explain which of the following options? A. Begin monthly breast self−examinations at age 40 B. Have a clinical breast examination each year after age 30 lOMoARcPSD| C.Begin annual mammograms at age 40 D. Have breast magnetic resonance imaging every 5 years after age 50 (Correct Answer)− C. Begin annual mammograms at age 40 Women should begin performing monthly breast self−examinations at 20 years of age. From 20 to 39 years of age, women should undergo a breast examination by a health care provider every 3 years. Women older than 40 years of age should have annual breast examinations by a health care provider and an annual mammogram. A nurse is preparing a client for a bronchoscope. Which of the following actions should the nurse take? (Select all that apply.) A. Explain that the client will receive sedation and will not remember the procedure. B. Verify that the client understands the purpose and nature of the procedure. C. Offer the client sips of clear liquids until 1hr before the test. D. Obtain a pre−procedural sputum specimen. E. Instruct the client to keep his neck in a neutral position. F.(Correct Answer)− A. Explain that the client will receive sedation and will not remember the procedure. For a bronchoscopy, clients typically receive premedication with a benzodiazepine or anopioidtoen sure sedation and amnesia. The client will have sign edaconsent form, so the nurse should verify that the provider explained the procedure and that the client understand sit. A nurse is assessing a client who has peripheral vascular disease and a venous ulcer on the right ankle. Which of the following findings should the nurse expect in the client's affected extremity? lOMoARcPSD| A. Absent pedal pulses B. Ankle swelling C. Hair loss D. Skin atrophy (Correct Answer)− B. Ankle swelling The nurse should identify that swelling of the ankle is a man if estuation of venous in sufficiency due to poor venous return. Other man if estation scan include brown pigmentation sand cell ulitis. A nurse in an emergency department is assessing a client who sustained a fall off of a roof. Which of the following findings should the nurse identify as an indication of a basilar skull fracture? A. Depressed fracture of the forehead B. Clear fluid coming from the nares C. Motor loss on one side of the body D. Bleeding from the top of the scalp (Correct Answer)− B. Clear fluid coming from the nares Cerebrospinal fluid manifests as a clear fluid coming from the nares or ears, indicating a basilar skull fracture. A nurse is caring for a client who has diabetes insipid us. For which of the following findings should the nurse monitor? lOMoARcPSD| A. Proteinuria B. Oliguria C. Polyuria D. Glycosuria (Correct Answer)− C. Polyuria A client is being discharged home with oxygen therapy delivered through an a salcannula. Which of the following instructions should the nurse provide to the client and family members? A. Use battery−operated equipment for personal care. B. Apply mineral oil to protect the facial skin from irritation. C. Remove the television set from the client's bedroom. D. Wear cotton clothing to avoid static electricity. (Correct Answer)− D. Wear cotton clothing to avoid static electricity. The use of cotton clothing will limit the build up of static electricity. Oxygen is a highly combustible gas. The use of oxygen in high concentrations has great combustion potential and readily fuels fire. Although it will not spontaneously burn or cause an explosion, it can easily cause a fire in a client's room if it contacts a spark. A nurse is removing personal protective equipment (PPE) after performing a procedure for a client who requires isolation precautions. Which of the following items of PPE should the nurse remove first? A. Gloves lOMoARcPSD| B. Gown C. Eyewear D. Mask(Correct Answer)− A nurse is monitoring a newly licensed nurse who is caring for a client. The client has active pulmonary tuberculosis, was placed on air borne precautions, and is scheduled for a chest X−ray. The nurse should instruct the newly licensed nurse to take which of the following actions? A. Have the client wear a surgical mask. B. Wear a gown for protection from the client's infection. C. Ask the radiology staff to perform a portable chest X−ray in the client's room. D. PlaceanN−95 respirator on the client. (Correct Answer)− A. Have the client wear a surgical mask. A nurse is assessing a client who has cholecystitis. Which of the following findings should the nurse expect? A. Blumberg's sign B. Ascites C. Gastrointestinal bleeding D. Kehr's sign (Correct Answer)− A. Blumberg's sign The nurse should expect to find rebound tenderness (Blumberg's sign) in a client who has cholecystitis. This response can be an indication of peritoneal inflammation. lOMoARcPSD| :B.The nurse should expect to find as cites in a client who has chronic pancreatitisor pancreatic cancer. B.The nurse should expect to find gastro intestinal bleeding in a client who has pancreatic cancer. C.The nurse should expect to find a positive Kehr's sign in a client who has liver trauma. A nurse is implementing cold therapy for a client who has an ankles prain. Which of the following actions should the nurse take? A.Apply a cold pack to the edematousarea B.Check capillary refill before applying an ice pack to the affected area C.Half−fill an ice pack with crushed ice D.Apply an ice pack for 60min intervals (Correct Answer)− B. Check capillary refill before applying an ice pack to the affected area The nurse should check the affected area for adequate circulation by assessing pulses and capillary refill because a cold pack applied to an area of impaired circulation can further decrease the blood supply to the area. A nurse is caring for a client following a stroke. Which of the following actions should the nurse take first? A.Obtain coagulation laboratory studies from the client B.Apply pneumatic compression boots to the client C.Request areferralfora speech−language pathologist D.Keep the client NPO lOMoARcPSD| (Correct Answer)− D. Keep the client NPO The first action the nurse should take when using the airway, breathing, and circulation(ABC) approach to client care is to keep the client NPO due to the risk of aspiration as a result of the stroke. The client should be screened for the ability to swallow and should not receive anything by mouth until this has been completed. A client who has experience dacerebro vascular accident is a trisk for dysphagia, which increases the change of life−threating aspiration. A nurse is providing discharge teaching to a client who has a new permanent pacemaker. Which of the following statements by the client indicates an under standing of the teaching? A. "I should check my heart rate at the same time each day." B."I don't have to take my antihypertensive medications now that I have a pacemaker." C."I should keep a pressure dressing over the generator until the incisions healed." D."I cannot stand in front of our new microwave oven when it is on. E. "(Correct Answer)− A."I should check my heart rate at the same time each day." The nurse should instruct the client to check the heart rate at the same time each day and to document the rate in a log for reporting to the provider. Incorrect Answers: B.A pacemaker maintains a regular heart rate but is not intended to lower blood pressure or control hypertension. C. The client should avoid applying pressure over the generator. D. New microwaves a reequipped with shielding that protects a person who has a pacemaker from interference. Hence, standing in front of a new microwave oven is not contraindicated. The client should avoid being in close proximity too lder micro waves that do not have this shielding. lOMoARcPSD| A nurse is caring for a client who has a percutaneous endoscopic gastrostomy (PEG) tube and is receiving intermittent feedings. Priortoinitiating the feeding, which of the following actions should the nurse take first? A. Flush the tube with water B. Place the client in the semi−Fowler's position C. Clean seethe skin around the tube site D. Aspirate the tube for residual contents (Correct Answer)− B. Place the client in the semi−Fowler's position The nurse should apply the ABC priority−setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breath inadequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alterationinany of these area scan indicate at heart to life and is the nurse's priority concern. When applying the ABC priority−setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second priority because adequate ventilator effort is essential for oxygen exchange to occur. Circulation is the third priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen them. A nurse is teaching a client how to perform range−of−motion exercises of the wrist. To perform adduction, which of the following instructions should the nurse include? A. "With your palm facing down, move your wrist sideways toward your thumb." B. "Move your palm toward the inner part of your forearm." C."With your palm facing down, move your wrist sideways toward your little finger." D. "Bring the back of your hand as far back toward the wrist as you can. "(Correct Answer)− a."With your palm facing down, move your wrist sideways toward lOMoARcPSD| your thumb." This motion describes adducting the wrist. The client should be able to move her wrist 30º to 50º with this motion. A nurse is caring for a client who is NPO and has an NG tube to suction. When the client reports nausea, which of the following actions should the nurse take? A. Irrigate the tube with normal saline solution B. Provide oral hygiene C. Clamp the tube for 30min D. Increase the amount of suction (Correct Answer)− A. Irrigate the tube with normal saline solution When a client with an NG tube develops nausea, the nurse should first attempt to irrigate the tube to determine patency. If the tube is not patent, gastric pressure cannot decrease, and the steady or increase in g pressure can cause nausea. A nurse is assessing a client who is 12 hr postoperative following an open cholecystectomy. Which of the following findings should the nurse report to the provider? A. Hypo active bowel sounds B. Indwelling urinary catheter output of 25mL/hr C. Heart rate of 96/min D. Serous drainage at the surgical incision site lOMoARcPSD| (Correct Answer)− B. Indwelling urinary catheter output of 25mL/hr The nurse should report a urinary output of 30mL/hr to the provider, as this can indicate hypo volemiaorrenal complication. A charge nurse is observing a newly licensed nurse administer an IV medication to a client who has an implanted venous access port .Which of the following observations requires intervention by the charge nurse? A. Addressing is not applied to the port site after use. B. A22−gaugenon−coringneedleis used to access the port. C. Blood return is not edprior to administering the medication. D.A solution of 5mLheparin1,000units/mL has been prepared. (Correct Answer)− D. A solution of 5mLheparin1,000units/mL has been prepared. Implanted ports should be flushed after each use and at least once a month when not in use. This practice is sometimes referred to as"locking"or"de−accessing. "It is perform edtoprevent the formation of blood clot sin the catheter, which would disrupt the proper functioning of the catheter .The solution of 5mLheparin should be 100 units /mL; therefore, this action requires intervention by the charge nurse. A nurse is providing discharge instructions to a client who is postoperative following surgical excision of a basal cell carcinoma. Which of the following findings should the nurse include as an indication of a mole's potential malignancy? lOMoARcPSD| A. Ulceration B. Blanching of surrounding skin C. Dimpling D. Fading of color (Correct Answer)− A. Ulceration Ulceration, bleeding, and exudation are indications of a mole's potential malignancy. Increasing size is also a warning sign. The nurse should emphasize the importance of life time follow− up evaluations and the proper techniques for self−examination of the skin every month