ATI Standard Quiz- Medical surgical Final Exam 2023/2024

A nurse is caring for a client who is to have his chest tube removed. Which of the following actions should the nurse take? A. Cover the insertion site with a hydrocolloid dressing after removal B. Provide pain medication immediately after removal C. Instruct the client to perform the Valsalva maneuver during removal D. Delegate removal of the chest tube to a LPN A nurse is caring for a client who is to have his chest tube removed. Which of the following actions should the nurse take? A. Cover the insertion site with a hydrocolloid dressing after removal B. Provide pain medication immediately after removal C. Instruct the client to perform the Valsalva maneuver during removal D. Delegate removal of the chest tube to a LPN - answers C The nurse should instruct the patient to perform the Valsalva maneuver during removal to maintain the appropriate amount of negative pressure in the chest to prevent air entry into the pleural space. A nurse is caring for a client who begins having a tonic clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first? A. Provide oxygen B. Place the client in a side lying position C. Provide privacy D. Lower the client to the floor - answers D A nurse is teaching a client how to perform a breast self exam. The nurse should identify which of the following findings as an indication of breast cancer? A. Lumps that are mobile and tender upon palpation prior to period B. Multiple round masses that are tender and found in both breasts C. Bilaterally darkened areolas D. A nontender, hard lump that is palpated in one breast - answers D A nurse is preparing to change the bed linens of a client who has AIDS and is continent of stool Which of the following PPE should the nurse don prior to providing client care (SATA)? A. Gown B. Gloves C. Mask D. Hair cover E. Goggles - answers A B 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 provider? A. Ecchymosis of the thigh B. Serous drainage at the pin site C. Chest petechiae D. Muscle spasms in left leg. - answers C A nurse is providing teaching about antiretroviral medication therapy to a client who has a new diagnosis of AIDS. Which of the following statements should the nurse include in the teaching? A. Your provider will prescribed one single antiretroviral medication at a time B. You should take antiretroviral medications on a routine schedule C. You should increase your intake of raw fruits and veggies while taking antiretroviral meds D. Your provider will prescribed antiretroviral therapy to kill the HIV virus - answers B A nurse is caring for a client who is 72 hr postoperative following an above the knee amputation. Which of the following actions should the nurse take? A. Elevate the residual limb on a soft pillow B. Assist the client to a prone position every 4 hour. C. Reapply a bandage to the residual limb every 12 hour D. Apply dressings to the site in a proximal to distal direction - answers B The nurse should assist the client to a prone position for 20-30 min every 3-4 hour following an amputation because it reduces the risk for flexion contractures A home health nurse enters a clients home and finds a used insulin syringe, without a cap, on the table. Which of the following action should the nurse take? A. Recap the needle on the syringe B. Schedule a nurse to administer future injections for this client C. Explain to the client that the syringe should be disposed of in the bathroom trash can D. Place the syringe in a puncture proof disposal container - answers D A nurse is caring for a client who has type 1 DM and a cap glucose reading of 48. Which of the following findings should the nurse expect? A. Kussmaul respirations B. Diaphoresis C. Decreased skin turgor D. Ketouria - answers B A nurse should expect a client who has a blood glucose level below 70 to exhibit manifestations of hypoglycemia. Expecting findings associated with hypoglycemia include weakness, hunger, diaphoresis, nausea, shakiness and confusion A nurse is providing teaching to a client who has TB and Rx for rifampin and ethambutol. The nurse should identify which of the following findings as an adverse effect these medications that the client should report to the provider? A. Red-orange discoloration of urine B. Unexpected weight gain C. Ringing in the ears D. Decreased visual acuity - answers D The nurse should identify optic neuritis as an adverse effect of ethambutol. The nurse should instruct the client to monitor for changes in visual acuity or color identifiycation as indications of optic neuritis to report to provider. A nurse is performing an admission assessment for a client who has asthma and report several food allergies. Which of the following actions should the nurse take first? A. Document the clients food allergies on the medical record B. Ask the client to identify the specific food allergies C. Monitor the client for indications of anaphylaxis D. Have epinephrine aviabale for administration - answers B A nurse is caring for a client who is receiving intermittent peritoneal dialysis. The nurse observes that the peritoneal fluid is not adequately draining. Which of the following actions should the nurse take? A. Turn the client from side to side B. Elevate the height of the dialysate bag C. Lower head of bed D. Advance the catheter approximately 2.5cm further - answers A The nurse should assist the client in turning from side to side to facilitate removal of peritoneal drainage. A nurse is providing discharge teaching to a client who has a new diagnosis of SLE. Which of the following statements by the client indicates an understanding of the teaching? A. I will need to take methotrexate even if Im in remission B. Im thankful that this type of lupus only affect the skin C. Each day I should apply a sunblock with a sun protection factor of 15 D. A mild fever is common with SLE and usually does not require medical intervention - answers A A nurse is providing discharge teaching about improving gas exchange to a client who has emphysema. Which of the following instructions should the nurse include in the teaching? A. Use pursed lip rbeahting during periods of dyspnea B. Limit fluid intake to 1,500mL per day C. Practice chest breathing each day D. Wear home oxygen to maintain an SaO2 of at least 94% - answers A A nurse is planning care for a client who has thrombophlebitis and a Rx to receive herpain via continuous IV infusion. Which of the following actions should the nurse include in the plan of care? A. Infuse the heparin using an electronic IV pump B. Administer vitamin K if the client has indications of hemorrhage C. Adjust the dosage of the heparin base don the PT levels D. Inform the client that the herpain will dissolve thrombus - answers A The nurse should administer heparin using an electronic IV pump, rather than by gravity, to prevent an accidental increase or change in the rate of infusion A nurse is caring for a client following a hip arthroplasty. The nurse places an abduction pillow on the client for which of the following purposes? A. Raising the bed linens off the clients feet to prevent plantar flexion B. Keeping the clients heels off the bed to prevent pressure ulcers C. Positioning the client off the operative site while in bed D. Preventing dislocation of the hip during position changes or movement - answers D A nurse is providing teaching to a client who has stomatitis due to chemo and radiation therapy. Which of the following statements by the client indicates a need for further teaching? A. I will use a soft toothbrush or foam swab for oral care B. I will use lemon and glycerin swabs after meals C. I will remove my dentures except while eating D. I will rinse my mouth frequ