Med surg- proctored ATI, question well done 2024’

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? - ANSWERSUrine 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? - ANSWERSAged 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? - ANSWERS"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? - ANSWERSCalcium 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? - ANSWERSHistory 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? - ANSWERSBradycardia 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? - ANSWERSUse 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? - ANSWERSAdminister 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). - ANSWERSCurrent 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? - ANSWERSInject 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? - ANSWERSUrine 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.) - ANSWERS167 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? - ANSWERSAdd 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? - ANSWERSLeukopenia