ATI Adult Med Surg Form B

A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Which of the following statements made by the client reflects an understanding of the teaching? A. I will need to take antibiotics for 1 year B. My partner will need to take an antiviral medication C. My joints ache because I have Lyme disease D. I bruise easily because I have Lyme disease C. My joints ache because I have Lyme disease RATIONALE: the disease course occurs in 3 stages beginning with joint and muscle pain in stage I. If left untreated, these symptoms continue through stage II and III and become chronic. Other chronic complications include memory problems and fatigue A nurse is caring for a client who is 4hr postoperative following an open reduction internal fixation of the right ankle. Which of the following assessment findings should the nurse report to the provider? A. Extremity cool upon palpation B. Serosanguinous drainage on the dressing C. Capillary refill of 2 seconds D. Client report of discomfort when moving toes A. Extremity cool upon palpation RATIONALE: this is an indication of reduced circulation, such as pallor, cool temp or paresthesia; these findings can indicate that the client is at risk for developing acute compartment syndrome A nurse is assessing a client while suctioning the client's tracheostomy tube. Which of the following findings should indicate to the nurse that the client is experiencing hypoxia? A. The client starts to cough B. The client's HR increases C. The client is diaphoretic D. The client's blood pressure decreases B. The client's HR increases RATIONALE: the nurse should instruct the client to take 3-4 deep breaths prior to suctioning to reduce risk of hypoxia A nurse is caring for a client who is 8hr postoperative following a total hip arthroplasty. The client is unable to void on the bedpan. Which of the following actions should the nurse take? A. Document the client's intake and output B. Scan the bladder with a portable ultrasound C. Pour warm water over the client's peritoneum D. Perform a straight catheterization B. Scan the bladder with a portable ultrasound RATIONALE: to determine the amount of urine in the bladder A nurse is providing discharge instructions to a client who has active TB. Which of the following information should the nurse include in the instructions? A. Sputum specimens are necessary every 2-4weeks until there are 3 negative sputum cultures B. The contagious period generally lasts for 6-8wks after the initiation of medication therapy C. Family members should follow airborne precautions at home D. A follow up TB skin test is necessary in 2 months A. Sputum specimens are necessary every 2-4weeks until there are 3 negative sputum cultures RATIONALE: After 3 negative sputum cultures, the client is no longer considered infectious B- the client's is usually no longer contagious after taking TB medications 2-3 weeks C- family members do not need to follow airborne precautions because they have already been exposed to TB D- a follow up eval needs to be a chest x-ray because the TB skin test is no longer considered accurate after a person has tested positive A nurse is caring for a client who has increased intracranial pressure and is receiving mannitol via continuous IV infusion. Which of the following findings should the nurse report to the provider as an adverse effect of this medication? A. Decreased HR B. Crackles heard on auscultation C. Increased UO D. Decreased DTRs B. Crackles heard on auscultation RATIONALE: Mannitol is an osmotic diuretic that prevents the reabsorption of water in the kidney's, thus increasing UO. With the exception of the brain, mannitol can leave the vascular system at the capillary site, which can result in edema. The nurse should identify crackles as a manifestation of pulmonary edema and notify the provider. Other manifestations include dyspnea and decreased O2 sats A nurse is providing discharge teaching to a client who is postoperative following a modified radical mastectomy. Which of the following instructions should the nurse include? A. Flex the affected arm when ambulating B. Numbness can occur along the inside of the affected arm C. Begin active range of motion exercises 1 day after surgery D. Dress in clothing that fits snugly B. Numbness can occur along the inside of the affected arm RATIONALE: numbness can occur near the incision and along the inside of the affected arm d/t nerve injury A- AVOID to reduce the risk of elbow contracture C- begin 1 WEEK after surgery to increase mobility without causing stress on the incision A nurse is providing education to a client who has TB and their family. Which of the following information should the nurse include in the teaching? A. After 1 week of medication, TB is no longer communicable B. Dispose of contaminated tissues in a paper bag C. Airborne precautions are necessary D. Family members in the household should undergo TB testing D. Family members in the household should undergo TB testing RATIONALE: C- airborne precautions are not necessary because they have already been exposed