ATI RN Med Surg: Final EXAM 2022
A nurse is planning dietary teaching for a client who has diabetes mellitus. Which of the
following actions should the nurse plan to take first?
Obtain sample menus from the dietitian to give to the client.
Ask the client to identify the types of foods she prefers.
Identify the recommended range for the client's blood glucose level.
Discuss long-term complications that can result from nonadherence to the dietary plan. -
CORRECT ANSWER Ask the client to identify the types of foods she prefers.
the nurse should first ask the client about individual food preferences to provide an
opportunity for the nurse to include these foods in her diet. Involving the client in the
planning will help promote her adherence to the dietary plan.
A nurse is caring for a client who has type 1 diabetes mellitus and a capillary blood
glucose reading of 48 mg/dL. Which of the following findings should the nurse expect?
Kussmaul respirations
Diaphoresis
Decreased skin turgor
Ketonuria - CORRECT ANSWER Diaphoresis
a client who has a blood glucose level below 70 mg/dL to exhibit manifestations of
hypoglycemia. Expected findings associated with hypoglycemia include weakness,
hunger, diaphoresis, nausea, shakiness, and confusion
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?
Elevate the residual limb on a soft pillow.
Assist the client to a prone position every 4 hr.
Reapply a bandage to the residual limb every 12 hr.
Apply dressings to the site in a proximal-to-distal direction. - CORRECT ANSWER
Assist the client to a prone position every 4 hr.
because it reduces the risk of flexion contractures.
A nurse is providing teaching to a client who has gout and urolithiasis. The client asks
how to prevent future uric acid stones. Which of the following suggestions should the
nurse make? (Select all that apply.)
A. Take allopurinol as prescribed.
, B. Exercise several times a week.
C. Limit intake of foods high in purine.
D. Decrease daily fluid intake.
E. Avoid citrus juices. - CORRECT ANSWER Take allopurinol as prescribed.
Exercise several times a week.
Limit intake of foods high in purine.
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
Clear fluid coming from the nares
Motor loss on one side of the body
Bleeding from the top of the scalp - CORRECT ANSWER Clear fluid coming from the
nares
The nurse should identify cerebrospinal fluid, which appears as a clear fluid, coming
from the nares or ears as an indication of a basilar skull fracture.
A nurse is teaching a client how to perform a breast self exam (BSE). The nurse should
identify which of the following findings as an indication of breast cancer?
Lumps that are mobile and tender upon palpation prior to a menstrual period
Multiple round masses that are tender and found in both breasts
Bilaterally darkened areolas
A nontender, hard lump that is palpated in one breast - CORRECT ANSWER A
nontender, hard lump that is palpated in one breast
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?
Use pursed-lip breathing during periods of dyspnea.
Limit fluid intake to 1,500 mL per day.
Practice chest breathing each day.
Wear home oxygen to maintain an SaO2 of at least 94%. - CORRECT ANSWER Use
pursed-lip breathing during periods of dyspnea.
A nurse is caring for a client who has an upper gastrointestinal bleed and a hematocrit
of 24%. Prior to initiating a transfusion of packed red blood cells (RBCs), which of the
following actions should the nurse take? (Select all that apply.)
Assess and document the client's vital signs.
Restart the IV with a 22-guage needle.
Verify with another nurse the blood type and Rh of the packed RBCs.
A nurse is planning dietary teaching for a client who has diabetes mellitus. Which of the
following actions should the nurse plan to take first?
Obtain sample menus from the dietitian to give to the client.
Ask the client to identify the types of foods she prefers.
Identify the recommended range for the client's blood glucose level.
Discuss long-term complications that can result from nonadherence to the dietary plan. -
CORRECT ANSWER Ask the client to identify the types of foods she prefers.
the nurse should first ask the client about individual food preferences to provide an
opportunity for the nurse to include these foods in her diet. Involving the client in the
planning will help promote her adherence to the dietary plan.
A nurse is caring for a client who has type 1 diabetes mellitus and a capillary blood
glucose reading of 48 mg/dL. Which of the following findings should the nurse expect?
Kussmaul respirations
Diaphoresis
Decreased skin turgor
Ketonuria - CORRECT ANSWER Diaphoresis
a client who has a blood glucose level below 70 mg/dL to exhibit manifestations of
hypoglycemia. Expected findings associated with hypoglycemia include weakness,
hunger, diaphoresis, nausea, shakiness, and confusion
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?
Elevate the residual limb on a soft pillow.
Assist the client to a prone position every 4 hr.
Reapply a bandage to the residual limb every 12 hr.
Apply dressings to the site in a proximal-to-distal direction. - CORRECT ANSWER
Assist the client to a prone position every 4 hr.
because it reduces the risk of flexion contractures.
A nurse is providing teaching to a client who has gout and urolithiasis. The client asks
how to prevent future uric acid stones. Which of the following suggestions should the
nurse make? (Select all that apply.)
A. Take allopurinol as prescribed.
, B. Exercise several times a week.
C. Limit intake of foods high in purine.
D. Decrease daily fluid intake.
E. Avoid citrus juices. - CORRECT ANSWER Take allopurinol as prescribed.
Exercise several times a week.
Limit intake of foods high in purine.
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
Clear fluid coming from the nares
Motor loss on one side of the body
Bleeding from the top of the scalp - CORRECT ANSWER Clear fluid coming from the
nares
The nurse should identify cerebrospinal fluid, which appears as a clear fluid, coming
from the nares or ears as an indication of a basilar skull fracture.
A nurse is teaching a client how to perform a breast self exam (BSE). The nurse should
identify which of the following findings as an indication of breast cancer?
Lumps that are mobile and tender upon palpation prior to a menstrual period
Multiple round masses that are tender and found in both breasts
Bilaterally darkened areolas
A nontender, hard lump that is palpated in one breast - CORRECT ANSWER A
nontender, hard lump that is palpated in one breast
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?
Use pursed-lip breathing during periods of dyspnea.
Limit fluid intake to 1,500 mL per day.
Practice chest breathing each day.
Wear home oxygen to maintain an SaO2 of at least 94%. - CORRECT ANSWER Use
pursed-lip breathing during periods of dyspnea.
A nurse is caring for a client who has an upper gastrointestinal bleed and a hematocrit
of 24%. Prior to initiating a transfusion of packed red blood cells (RBCs), which of the
following actions should the nurse take? (Select all that apply.)
Assess and document the client's vital signs.
Restart the IV with a 22-guage needle.
Verify with another nurse the blood type and Rh of the packed RBCs.
