ATI PN Adult Medical Surgical Online Practice 2020 B
A nurse is assisting with the development of a plan of care to manage pain for a
client who has herpes zoster with lesions on the lower extremities. Which of the
following interventions should the nurse include in the plan of care? - ANSWER
Keep bed linens o of the affected areas. The nurse should keep bed linens off of the
affected areas by using a bed cradle, which will relieve pain caused by the linens
rubbing against the lesions.
A nurse in an orthopedic clinic is reinforcing teaching with a client who has
osteoarthritis. Which of the following instructions should the nurse include to promote
comfort? - ANSWER Sleep on a firm mattress. A firm mattress or a bed board
helps the client maintain joint alignment while sleeping.
A nurse is caring for a client who has an intestinal obstruction and reports a new
onset of nausea. The client has an NG tube set at low intermittent suction and is
receiving continuous IV infusion of 0.9% sodium chloride. Which of the following
actions should the nurse take first? - ANSWER Check for kinks in the NG tube.
The first action the nurse should take when using the nursing process is to collect
data from the client. Therefore, the priority action is to check the NG tube to
determine if the tube is kinked, which can interfere with the suctioning function and
result in nausea.
A nurse is assisting in the care of a client who has AIDS-related pneumonia. The
client is receiving antibiotic therapy and albuterol nebulizer treatments daily. Which
of the following findings should indicate to the nurse that the client's therapeutic
regimen is effective? - ANSWER Decrease in exertional dyspnea. A decrease in
exertional dyspnea indicates the antibiotics are resolving the infection and the
albuterol treatments are facilitating effective ventilation. Therefore, the nurse should
evaluate the therapeutic regimen as effective for the client.
A nurse is caring for a client who is in Buck's traction for a fractured hip. The client
reports increased pain at the site of the fracture. Which of the following actions
should the nurse take? - ANSWER Reposition the client. When the client's body is
out of alignment with the traction, muscle spasms develop, causing increased pain.
Therefore, the nurse should reposition the client, ensuring there is a straight line
from the client's hip to the traction rope and pulley, evaluate the client's response,
and provide other interventions as needed.
A nurse is caring for a client who begins to have a seizure while ambulating in the
hall. Identify the sequence of actions the nurse should follow. (Move the steps into
the box on the right, placing them in the order of performance. Use all the steps.) -
ANSWER Lower the client to the floor. to prevent the pt from falling.
Place a pad beneath the client's head. to protect the pt from injury
Loosen the clothing around the client's neck. to allow for easier ventilation
Time the length of the client's seizure. for accurate reporting
, Reorient and reassure the client. because confusion and embarrassment are
common
A nurse is reinforcing teaching with a client who has diabetes mellitus and a new
prescription for regular and NPH insulin. Which of the following instructions on
preparing the insulins should the nurse include? - ANSWER Withdraw the regular
insulin before withdrawing the NPH insulin. The nurse should instruct the client to
withdraw the regular insulin before withdrawing the NPH insulin. This will protect the
regular insulin from contamination with the NPH insulin.
A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus about
glycosylated hemoglobin (HbA1c) testing. Which of the following information should
the nurse include in the teaching? - ANSWER HbA1c results measure glucose
control for the prior 3 months. HbA1c testing reflects average overall glucose control
over a 3-month period. The nurse should inform the client that HbA1c testing is the
best measure of long-term glucose control.
A nurse is collecting data from a client who has 30% body surface area deep partial-
thickness and full-thickness burns. Which of the following findings indicates that fluid
resuscitation is adequate? - ANSWER Urine output is 50 mL/hr. The nurse should
closely monitor the client's urinary output as an indicator of effective fluid
resuscitation. A urinary output greater than 30 to 50 mL/hr indicates that fluid
resuscitation is adequate.
A nurse is planning care for a group of clients after receiving change-of-shift report.
Which of the following clients should the nurse plan to see first? - ANSWER A
client who is dehydrated, has mental confusion, and has tried to get out of bed
several times during the night. When using the urgent vs. nonurgent approach to
client care, the nurse should determine that a client who has mental confusion and is
getting out of bed without assistance is the first client the nurse should see. This
client is experiencing manifestations of dehydration, which increases the risk for falls.
A nurse is reinforcing teaching with a client who has a new diagnosis of genital
herpes. Which of the following information should the nurse include? - ANSWER
"The virus can be transmitted without lesions being present." The nurse should
inform the client that viral shedding and spreading of the infection can occur even
when lesions are not present.
A nurse is collecting data from a client who has an obstructive pulmonary disorder.
The nurse should document the sound as which of the following? (Click on the audio
button to listen to the clip.) - ANSWER Wheezes. The nurse should identify the
breath sound auscultated as wheezes. These are high-pitched, musical sounds that
occur as air passes through narrowed airways, such as when a client is experiencing
an asthma attack.
A nurse is reviewing the medication record of a client who is taking digoxin. Which of
the following medications should the nurse identify as increasing the risk for the
client to develop digoxin toxicity? - ANSWER Furosemide. the nurse should
identify that loop diuretics, such as furosemide, increase the urinary excretion of
A nurse is assisting with the development of a plan of care to manage pain for a
client who has herpes zoster with lesions on the lower extremities. Which of the
following interventions should the nurse include in the plan of care? - ANSWER
Keep bed linens o of the affected areas. The nurse should keep bed linens off of the
affected areas by using a bed cradle, which will relieve pain caused by the linens
rubbing against the lesions.
A nurse in an orthopedic clinic is reinforcing teaching with a client who has
osteoarthritis. Which of the following instructions should the nurse include to promote
comfort? - ANSWER Sleep on a firm mattress. A firm mattress or a bed board
helps the client maintain joint alignment while sleeping.
A nurse is caring for a client who has an intestinal obstruction and reports a new
onset of nausea. The client has an NG tube set at low intermittent suction and is
receiving continuous IV infusion of 0.9% sodium chloride. Which of the following
actions should the nurse take first? - ANSWER Check for kinks in the NG tube.
The first action the nurse should take when using the nursing process is to collect
data from the client. Therefore, the priority action is to check the NG tube to
determine if the tube is kinked, which can interfere with the suctioning function and
result in nausea.
A nurse is assisting in the care of a client who has AIDS-related pneumonia. The
client is receiving antibiotic therapy and albuterol nebulizer treatments daily. Which
of the following findings should indicate to the nurse that the client's therapeutic
regimen is effective? - ANSWER Decrease in exertional dyspnea. A decrease in
exertional dyspnea indicates the antibiotics are resolving the infection and the
albuterol treatments are facilitating effective ventilation. Therefore, the nurse should
evaluate the therapeutic regimen as effective for the client.
A nurse is caring for a client who is in Buck's traction for a fractured hip. The client
reports increased pain at the site of the fracture. Which of the following actions
should the nurse take? - ANSWER Reposition the client. When the client's body is
out of alignment with the traction, muscle spasms develop, causing increased pain.
Therefore, the nurse should reposition the client, ensuring there is a straight line
from the client's hip to the traction rope and pulley, evaluate the client's response,
and provide other interventions as needed.
A nurse is caring for a client who begins to have a seizure while ambulating in the
hall. Identify the sequence of actions the nurse should follow. (Move the steps into
the box on the right, placing them in the order of performance. Use all the steps.) -
ANSWER Lower the client to the floor. to prevent the pt from falling.
Place a pad beneath the client's head. to protect the pt from injury
Loosen the clothing around the client's neck. to allow for easier ventilation
Time the length of the client's seizure. for accurate reporting
, Reorient and reassure the client. because confusion and embarrassment are
common
A nurse is reinforcing teaching with a client who has diabetes mellitus and a new
prescription for regular and NPH insulin. Which of the following instructions on
preparing the insulins should the nurse include? - ANSWER Withdraw the regular
insulin before withdrawing the NPH insulin. The nurse should instruct the client to
withdraw the regular insulin before withdrawing the NPH insulin. This will protect the
regular insulin from contamination with the NPH insulin.
A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus about
glycosylated hemoglobin (HbA1c) testing. Which of the following information should
the nurse include in the teaching? - ANSWER HbA1c results measure glucose
control for the prior 3 months. HbA1c testing reflects average overall glucose control
over a 3-month period. The nurse should inform the client that HbA1c testing is the
best measure of long-term glucose control.
A nurse is collecting data from a client who has 30% body surface area deep partial-
thickness and full-thickness burns. Which of the following findings indicates that fluid
resuscitation is adequate? - ANSWER Urine output is 50 mL/hr. The nurse should
closely monitor the client's urinary output as an indicator of effective fluid
resuscitation. A urinary output greater than 30 to 50 mL/hr indicates that fluid
resuscitation is adequate.
A nurse is planning care for a group of clients after receiving change-of-shift report.
Which of the following clients should the nurse plan to see first? - ANSWER A
client who is dehydrated, has mental confusion, and has tried to get out of bed
several times during the night. When using the urgent vs. nonurgent approach to
client care, the nurse should determine that a client who has mental confusion and is
getting out of bed without assistance is the first client the nurse should see. This
client is experiencing manifestations of dehydration, which increases the risk for falls.
A nurse is reinforcing teaching with a client who has a new diagnosis of genital
herpes. Which of the following information should the nurse include? - ANSWER
"The virus can be transmitted without lesions being present." The nurse should
inform the client that viral shedding and spreading of the infection can occur even
when lesions are not present.
A nurse is collecting data from a client who has an obstructive pulmonary disorder.
The nurse should document the sound as which of the following? (Click on the audio
button to listen to the clip.) - ANSWER Wheezes. The nurse should identify the
breath sound auscultated as wheezes. These are high-pitched, musical sounds that
occur as air passes through narrowed airways, such as when a client is experiencing
an asthma attack.
A nurse is reviewing the medication record of a client who is taking digoxin. Which of
the following medications should the nurse identify as increasing the risk for the
client to develop digoxin toxicity? - ANSWER Furosemide. the nurse should
identify that loop diuretics, such as furosemide, increase the urinary excretion of
