ATI med surg proctored exam2/214
Questions with 100% correct
answers/Latest update/Verified
A nurse is planning care for a client who has a full-thickness burns on the lower
extremities. Which of the following interventions should the nurse include?
a) Limit visitation time for client's children to 40 minutes per day
b) clean the equipment in the client's room once per week
c) provide a diet of fresh fruits and vegetable for the client
d) apply new gloves when alternating between wound care sites - -d) apply new
gloves when alternating between wound care sites
-A nurse is caring for a client who has cancer. The client tells the nurse, "I would
prefer to try vitamins and minerals instead of chemotherapy" which of the
following responses should the nurse make?
a) I have never heard of any holistic treatment that is effective
b) you should ask your provider about your plan
c) the best way to treat your cancer is chemotherapy
d) tell me what you know about chemotherapy - -d) tell me what you know about
chemotherapy
-A nurse is planning to teach a client whose provider has prescribed a low purine
diet. The nurse should plan to instruct the client that he can include which of the
following Foods in his diet (select all that apply)
a) Sardines
b) Nuts
c) Apricots
d) liver
e) scallops - -b) Nuts
c) Apricots
-Nurse is caring for a client following a total knee arthroplasty. The client reports
a pain level of 6 on a paint scale of 0 to 10. Which of the following interventions
should the nurse take?
a) Place pillowsl under the clients knee
b) gently massage the area around the clients incision
c) apply an ice pack to the clients knee
d) perform range of motion exercises to the clients knee - -c) apply an ice pack to
the clients knee
-A nurse is caring for a client who has lower extremity fracture and a prescription
for crutches. Which of the following client statements indicates that the client is
adapting to their role change? a) I will need to have my partner take over shopping
for groceries and cooking the meals for us
b) Its going to be difficult to tell my parents I can't take them to their appointments
anymore
c) I feel bad that I have to ask my partner to keep the house clean
,d) These crutches will make it impossible to care for my child - -a) I will need to
have my partner take over shopping for groceries and cooking the meals for us
-A nurse is assessing a client who is preoperative and reports an allergy to
bananas. The nurse should recognize that the client is at risk for an allergic cross-
reactivity to which of the following substances?
a) adhesive tape
b) Latex
c) Anesthetics
d) povidone iodine - -b) Latex
-A nurse on a medical unit is planning care for a group of clients. Which of the
following clients should the nurse attend to First?
a) A client who has chronic obstructive pulmonary disease in oxygen saturation of
89%
b) a client who has left-sided paralysis and slurred speech from a prior stroke
c) a client who has thrombocytopenia and reports a nosebleed
d) a client who has multiple sclerosis and reports Ataxia and vertigo - -c) a client
who has thrombocytopenia and reports a nosebleed
-A nurse is monitoring a client who is receiving two units packed RBC's. Which of
the following manifestation indicates a hemolytic transfusion reaction?
a) back pain
b) Hypertension
c) Chills
d) bradycardia - -a) back pain
-A nurse is teaching a client who has diabetes mellitus about foot care. Which of
the following instruction should the nurse include?
a) Use a heating pad to keep your feet warm at night
b) wear loose-fitting slippers around the house
c) where cotton rather than nylon socks
d) wash your face twice per day with antibacterial soap and hot water - -c) where
cotton rather than nylon socks
-A nurse is providing teaching to a client who has a deep vein thrombosis (DVT) .
Which of the following findings should the nurse identify as a risk factor for the
development of the DVTs?
a) NSAID use
b) hypertension
c) oral contraceptive use
d) cirrhosis - -c) oral contraceptive use
-A nurse is caring for a client who has a sealed radiation implant. Which of the
following actions should the nurse take?
a) Remove soiled linens from the room after each change
b) Give the dosimeter badge to the oncoming nurse at the end of the shift
c) Apply a second pair of gloves before touching the client's implant if it dislodges
d) Limit family member visits to 30 min per day - -d) Limit family member visits to
30 min per day
, -A nurse is providing teaching to a client and his partner about performing
peritoneal dialysis at home. When discussing peritonitis, which of the following
manifestations should the nurse identify as the earliest indication of this
complication?
a) Generalized abdominal pain b) Cloudy effluent
c) Increased heart rate
d) Fever - -d) Fever
-A nurse is caring for a client who is receiving a blood transfusion. The nurse
observes that the client has bounding peripheral pulses, hypertension, and
distended jugular veins. The nurse should anticipate administering which of the
following prescribed medications?
a) Pantoprazole
b) Acetaminophen
c) Furosemide
d) Diphenhydramine - -c) Furosemide
-A nurse is planning care for a client who has upper gastrointestinal bleeding due
to a peptic ulcer. Which of the following actions should the nurse plan to take?
a) Provide ketorolac for abdominal pain
b) Administer nitroprusside IV based on the client's weight
c) Insert a large bore nasogastric tube
d) Ensure that the client has a 22- gauge iv line in place - -c) Insert a large bore
nasogastric tube
-A nurse is caring for a client who has bladder cancer and a WBC count of
900/mm3. Which of the following actions should the nurse take?
a) Instruct client to avoid eating raw fruit
b) Move the client to a negative pressure room
c) Use contact isolation while providing care
d) Apply pressure to venipuncture sites for 10 min - -a) Instruct client to avoid
eating raw fruit
-A nurse is caring for a patient who has hypotension, cool and clammy skin,
tachycardia and tachypnea. Which of the following positions should the nurse
place the client?
a) Reverse Trendelenburg
b) Feet elevated
c) Side lying
d) High - fowler's - -a) Reverse Trendelenburg
-A nurse is caring for a client who weighs 190 lb and is receiving Total parenteral
Nutrition. If the RDA Protein is 0.8g/kg of body weight, how many grams of
protein should the client receive daily (Round the answer to the nearest whole
number. Use a leading zero if it applies. Do not use a trailing zero) - -Answer: 69
grams
-A nurse is planning care for a client who has a central venous access device for
intermittent infusions. Which of the following actions should the nurse include in
the plan of care?
a) Flush a catheter using a 10 mL syringe
, b) Use clean technique when changing the dressing
c) Cleanse the site with Provo dine iodine
d) Change the dressing every 24 hours - -a) Flush a catheter using a 10 mL syringe
-A nurse is reviewing the medical record of a client who is to undergo open heart
surgery. Which of the following findings should the nurse report to the provider as
a contradiction to receiving heparin?
a) Thalassemia
b) Rheumatoid arthritis
c) COPD
d) Thrombocytopenia - -d) Thrombocytopenia
-A nurse is caring for an older adult client who has dementia. Which of the
following question should the nurse ask to assess the client's abstract thinking?
a) What is meant by saying "don't beat around the bush?" b) What do you
understand about your condition?
c) Can you count backwards from 100 in intervals of 7?
d) Can you state where you were born? - -a) What is meant by saying "don't beat
around the bush?"
-A Nurse is completing an assessment of an older adult 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?
a) Apply an occlusive dressing b) turn and reposition the client every 4 hours
c) support bony prominences with pillows
d) massage Tourette in areas three times daily - -c) support bony prominences
with pillows
-A nurse is reviewing a cardiac Rhythm strip of a client who has atrial flutter.
Which of the following findings should the nurse expect?
a) Progressively longer PR durations
b) undetectable p waves
c) absent PR intervals with ventricular rate of 40 to 60 / minutes
d) Sawtooth pattern with atrial rate of 252 400 / minutes - -d) Sawtooth pattern
with atrial rate of 252 400 / minutes
-A nurse is caring for a client who is scheduled for an abdominal paracentesis. The
nurse should plan to take which of the following actions?
a) Administer a stool softener following the procedure
b) ask the client to empty his bladder prior to the procedure
c) instruct the client to take deep breaths and hold them during the procedure
d) assist the client into the left lateral position during the procedure - -b) ask the
client to empty his bladder prior to the procedure
-A nurse is caring for a client admitted with a skull fracture. Which of the
following assessment findings should be of greatest concern to the nurse?
a) Pulse pressure changes from 30 to 20 mmhg
b) bilateral pupil diameter changes from 4 to 2 mm
c) WBC count changes from 9,000 to 16,000 / mm 3
d) Glasgow Coma Scale score changes from 14 to 9 - -d) Glasgow Coma Scale score
changes from 14 to 9
Questions with 100% correct
answers/Latest update/Verified
A nurse is planning care for a client who has a full-thickness burns on the lower
extremities. Which of the following interventions should the nurse include?
a) Limit visitation time for client's children to 40 minutes per day
b) clean the equipment in the client's room once per week
c) provide a diet of fresh fruits and vegetable for the client
d) apply new gloves when alternating between wound care sites - -d) apply new
gloves when alternating between wound care sites
-A nurse is caring for a client who has cancer. The client tells the nurse, "I would
prefer to try vitamins and minerals instead of chemotherapy" which of the
following responses should the nurse make?
a) I have never heard of any holistic treatment that is effective
b) you should ask your provider about your plan
c) the best way to treat your cancer is chemotherapy
d) tell me what you know about chemotherapy - -d) tell me what you know about
chemotherapy
-A nurse is planning to teach a client whose provider has prescribed a low purine
diet. The nurse should plan to instruct the client that he can include which of the
following Foods in his diet (select all that apply)
a) Sardines
b) Nuts
c) Apricots
d) liver
e) scallops - -b) Nuts
c) Apricots
-Nurse is caring for a client following a total knee arthroplasty. The client reports
a pain level of 6 on a paint scale of 0 to 10. Which of the following interventions
should the nurse take?
a) Place pillowsl under the clients knee
b) gently massage the area around the clients incision
c) apply an ice pack to the clients knee
d) perform range of motion exercises to the clients knee - -c) apply an ice pack to
the clients knee
-A nurse is caring for a client who has lower extremity fracture and a prescription
for crutches. Which of the following client statements indicates that the client is
adapting to their role change? a) I will need to have my partner take over shopping
for groceries and cooking the meals for us
b) Its going to be difficult to tell my parents I can't take them to their appointments
anymore
c) I feel bad that I have to ask my partner to keep the house clean
,d) These crutches will make it impossible to care for my child - -a) I will need to
have my partner take over shopping for groceries and cooking the meals for us
-A nurse is assessing a client who is preoperative and reports an allergy to
bananas. The nurse should recognize that the client is at risk for an allergic cross-
reactivity to which of the following substances?
a) adhesive tape
b) Latex
c) Anesthetics
d) povidone iodine - -b) Latex
-A nurse on a medical unit is planning care for a group of clients. Which of the
following clients should the nurse attend to First?
a) A client who has chronic obstructive pulmonary disease in oxygen saturation of
89%
b) a client who has left-sided paralysis and slurred speech from a prior stroke
c) a client who has thrombocytopenia and reports a nosebleed
d) a client who has multiple sclerosis and reports Ataxia and vertigo - -c) a client
who has thrombocytopenia and reports a nosebleed
-A nurse is monitoring a client who is receiving two units packed RBC's. Which of
the following manifestation indicates a hemolytic transfusion reaction?
a) back pain
b) Hypertension
c) Chills
d) bradycardia - -a) back pain
-A nurse is teaching a client who has diabetes mellitus about foot care. Which of
the following instruction should the nurse include?
a) Use a heating pad to keep your feet warm at night
b) wear loose-fitting slippers around the house
c) where cotton rather than nylon socks
d) wash your face twice per day with antibacterial soap and hot water - -c) where
cotton rather than nylon socks
-A nurse is providing teaching to a client who has a deep vein thrombosis (DVT) .
Which of the following findings should the nurse identify as a risk factor for the
development of the DVTs?
a) NSAID use
b) hypertension
c) oral contraceptive use
d) cirrhosis - -c) oral contraceptive use
-A nurse is caring for a client who has a sealed radiation implant. Which of the
following actions should the nurse take?
a) Remove soiled linens from the room after each change
b) Give the dosimeter badge to the oncoming nurse at the end of the shift
c) Apply a second pair of gloves before touching the client's implant if it dislodges
d) Limit family member visits to 30 min per day - -d) Limit family member visits to
30 min per day
, -A nurse is providing teaching to a client and his partner about performing
peritoneal dialysis at home. When discussing peritonitis, which of the following
manifestations should the nurse identify as the earliest indication of this
complication?
a) Generalized abdominal pain b) Cloudy effluent
c) Increased heart rate
d) Fever - -d) Fever
-A nurse is caring for a client who is receiving a blood transfusion. The nurse
observes that the client has bounding peripheral pulses, hypertension, and
distended jugular veins. The nurse should anticipate administering which of the
following prescribed medications?
a) Pantoprazole
b) Acetaminophen
c) Furosemide
d) Diphenhydramine - -c) Furosemide
-A nurse is planning care for a client who has upper gastrointestinal bleeding due
to a peptic ulcer. Which of the following actions should the nurse plan to take?
a) Provide ketorolac for abdominal pain
b) Administer nitroprusside IV based on the client's weight
c) Insert a large bore nasogastric tube
d) Ensure that the client has a 22- gauge iv line in place - -c) Insert a large bore
nasogastric tube
-A nurse is caring for a client who has bladder cancer and a WBC count of
900/mm3. Which of the following actions should the nurse take?
a) Instruct client to avoid eating raw fruit
b) Move the client to a negative pressure room
c) Use contact isolation while providing care
d) Apply pressure to venipuncture sites for 10 min - -a) Instruct client to avoid
eating raw fruit
-A nurse is caring for a patient who has hypotension, cool and clammy skin,
tachycardia and tachypnea. Which of the following positions should the nurse
place the client?
a) Reverse Trendelenburg
b) Feet elevated
c) Side lying
d) High - fowler's - -a) Reverse Trendelenburg
-A nurse is caring for a client who weighs 190 lb and is receiving Total parenteral
Nutrition. If the RDA Protein is 0.8g/kg of body weight, how many grams of
protein should the client receive daily (Round the answer to the nearest whole
number. Use a leading zero if it applies. Do not use a trailing zero) - -Answer: 69
grams
-A nurse is planning care for a client who has a central venous access device for
intermittent infusions. Which of the following actions should the nurse include in
the plan of care?
a) Flush a catheter using a 10 mL syringe
, b) Use clean technique when changing the dressing
c) Cleanse the site with Provo dine iodine
d) Change the dressing every 24 hours - -a) Flush a catheter using a 10 mL syringe
-A nurse is reviewing the medical record of a client who is to undergo open heart
surgery. Which of the following findings should the nurse report to the provider as
a contradiction to receiving heparin?
a) Thalassemia
b) Rheumatoid arthritis
c) COPD
d) Thrombocytopenia - -d) Thrombocytopenia
-A nurse is caring for an older adult client who has dementia. Which of the
following question should the nurse ask to assess the client's abstract thinking?
a) What is meant by saying "don't beat around the bush?" b) What do you
understand about your condition?
c) Can you count backwards from 100 in intervals of 7?
d) Can you state where you were born? - -a) What is meant by saying "don't beat
around the bush?"
-A Nurse is completing an assessment of an older adult 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?
a) Apply an occlusive dressing b) turn and reposition the client every 4 hours
c) support bony prominences with pillows
d) massage Tourette in areas three times daily - -c) support bony prominences
with pillows
-A nurse is reviewing a cardiac Rhythm strip of a client who has atrial flutter.
Which of the following findings should the nurse expect?
a) Progressively longer PR durations
b) undetectable p waves
c) absent PR intervals with ventricular rate of 40 to 60 / minutes
d) Sawtooth pattern with atrial rate of 252 400 / minutes - -d) Sawtooth pattern
with atrial rate of 252 400 / minutes
-A nurse is caring for a client who is scheduled for an abdominal paracentesis. The
nurse should plan to take which of the following actions?
a) Administer a stool softener following the procedure
b) ask the client to empty his bladder prior to the procedure
c) instruct the client to take deep breaths and hold them during the procedure
d) assist the client into the left lateral position during the procedure - -b) ask the
client to empty his bladder prior to the procedure
-A nurse is caring for a client admitted with a skull fracture. Which of the
following assessment findings should be of greatest concern to the nurse?
a) Pulse pressure changes from 30 to 20 mmhg
b) bilateral pupil diameter changes from 4 to 2 mm
c) WBC count changes from 9,000 to 16,000 / mm 3
d) Glasgow Coma Scale score changes from 14 to 9 - -d) Glasgow Coma Scale score
changes from 14 to 9
