ATI PN Adult Medical Surgical Online Practice 2020 A

A nurse is caring for a client who is 3 days postoperative following a total right hip arthroplasty. Which of the following actions should the nurse take? Use a traction boot to keep the client's right leg internally rotated. Have the client sit in a reclining chair when out of bed. Maintain abduction of the client's right leg while in bed. Encourage the client to perform passive range-of-motion exercises. - Maintain abduction of the client's right leg while in bed. A nurse is caring for a client who has terminal pancreatic cancer. The client states, "I don't think I can go on any longer." Which of the following responses should the nurse make? "Are you experiencing abdominal pain?" "You should talk about this with the people you're closest to." "Many people who have cancer feel this way." "You feel like you want to discontinue treatment?" - "You feel like you want to discontinue treatment?" A nurse is contributing to the plan of care for a client who is having difficulty eating following a stroke. Which of the following actions should the nurse take first? Collaborate with a dietitian. Ensure that the client is provided with a high-ber diet. Implement recommendations from the speech-language pathologist. Request a referral for an occupational therapist. - Implement recommendations from the speech-language pathologist. A nurse is contributing to the plan of care for a client who was admitted to the neurological unit following a stroke 3 hr ago. Which of the following interventions should the nurse identify as the priority? Encourage the client to participate in self-care. Assist the client with active range-of-motion exercises. Keep the client in a side-lying position. Maintain the client's body alignment - Keep the client in a side-lying position. A nurse is participating in a health fair for older adult clients. Which of the following vaccines should the nurse recommend for this age group? Meningococcal Herpes zoster Human papillomavirus (HPV) Measles, mumps, and rubella (MMR) - Herpes zoster A nurse is contributing to the plan of care for a client who has a new prescription for nystatin suspension for oral candidiasis. Which of the following interventions should the nurse include in the plan? Use a commercial mouthwash before taking the medication. Instruct the client to swish the medication in their mouth. Discontinue the medication as soon as the lesions are healed. Combine the medication with applesauce - Instruct the client to swish the medication in their mouth. A nurse is preparing to perform intermittent urinary catheterization for a female client who has been unable to void following surgery 6 hr ago. Which of the following catheters should the nurse use to perform this procedure? - intermittent straight catheter (clear tube with blue top) A nurse is preparing to auscultate the bowel sounds of a client who has a mechanical bowel obstruction in the descending colon. When listening in the left upper quadrant, the nurse should identify this sound as which of the following? Hyperactive bowel sounds Friction rub Normal bowel sounds Abdominal bruit - Hyperactive bowel sounds A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking dantrolene to manage muscle spasms. Which of the following interventions should the nurse include? Apply hot packs to the client's muscles. Schedule physical therapy in the afternoon Encourage the client to complete ADLs. Administer valerian to promote sleep - Encourage the client to complete ADLs. A nurse is assisting with the care of a client who had a cardiac catheterization via the right femoral artery. Which of the following actions should the nurse take to prevent postprocedure complications? Monitor the insertion site for bleeding Position the affected extremity at a 45º Restrict the client's fluid intake Maintain the pressure dressing Check the client's peripheral pulses - Monitor the insertion site for bleeding is Maintain the pressure dressing Check the client's peripheral pulses A home health nurse is reinforcing teaching about preventing asthma attacks with a client who has asthma. Which of the following instructions should the nurse include in the teaching? "Cover the floor of your bedroom with carpet." "Do not allow visitors to smoke cigarettes in your home." "Breathe cold air to ease feelings of shortness of breath." "Open the windows in your home during the spring to increase air flow." - "Do not allow visitors to smoke cigarettes in your home." A nurse is caring for a client who has a prescription for phenazopyridine. Which of the following findings should the nurse identify as a therapeutic effect of the medication? Reduces bacteria in the urinary tract Suppresses urge to void Prevents nerve stimulation to the bladder muscle Decreases pain during urination - Decreases pain during urination A nurse is monitoring a client who is taking acarbose. Which of the following findings should the nurse identify as an adverse effect of the medication? Polyuria Abdominal cramps Renal insufficiency Insomnia - Abdominal cramps A nurse is caring for a client who has a new cast on their left forearm and reports severe pain in the affected arm with numbness in the ngers. The nurse nds the skin is pale and cold with sluggish capillary refill. Which of the following fracture complications should the nurse suspect? Compartment syndrome Fat embolism Deep-vein thrombosis Osteomyelitis - Compartment Syndrome A nurse is assisting with the discharge planning for a client who is postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the discharge plan? Expect decreased sensation for the rst postoperative week. Avoid lying on the operative side. Obtain a raised toilet seat. Cross legs at the ankles - Obtain a raised toilet seat. A nurse is assisting in the care of a client who has manifestations of sepsis. Which of the following provider prescriptions should the nurse implement first? Collect a sputum culture Administer ceftriaxone by intermittent IV bolus. Initiate oxygen at 4 L/min via nasal cannula Obtain blood cultures. - Initiate oxygen at 4 L/min via nasal cannula A nurse is reviewing the laboratory results of a client who has type 2 diabetes mellitus. The nurse should identify that which of the following laboratory values indicates the client is at risk for delayed wound healing? HbA1c 6% Prealbumin 12 mg/dL WBC count 8,000/mm3 Creatinine 0.8 mg/dL - Prealbumin 12 mg/dL A nurse is contributing to the plan of care for a client who has a methicillinresistant Staphylococcus aureus (MRSA) infection and is on contact isolation precautions. Which of the following actions should the nurse take? Keep the door of the client's room closed at all times. Remove gloves after leaving the client's room. Wear a mask when working within 1 m (3 feet) of the client. Have a designated stethoscope in the client's room. - Have a designated stethoscope in the client's room. A nurse is caring for a client who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days ago. Which of the following actions should the nurse take? Perform pin site care daily. Remove the overbed trapeze. Remove the boot every 2 hr. Keep the weights on a stable, at surface. - Perform pin site care daily. A nurse is monitoring a client who has a history of an enlarged prostate and is experiencing suprapubic discomfort. Which of the following actions should the nurse take first? Administer doxazosin. Palpate the abdomen. Insert an indwelling urinary catheter. Notify the provider. - Palpate the abdomen. A nurse is collecting data from a client who has heart failure and is taking digoxin. Which of the following outcomes from the medication should the nurse expect? Increased weight Increased heart rate Decreased urinary output Decreased shortness of breath - Decreased shortness of breath A nurse is assisting in the plan of care for a client who had a recent left hemispheric stroke. Which of the following actions should the nurse include in the plan? Observe for impulsive behavior. Approach the client from the right side. Use simple verbal cues when directing tasks. Place the client in low-Fowler's position during meals. - Use simple verbal cues when directing tasks A nurse is reinforcing teaching with the caregiver of a client who is terminally ill about manifestations of impending death. Which of the following manifestations should the nurse include? Incontinence of the bowel and bladder Increase in heart rate Warmness of the skin Hypertension - Incontinence of the bowel and bladder A nurse is reinforcing teaching with a client who is taking insulin glargine. Which of the following information should the nurse include in the teaching? "This type of insulin should be given at the same time every day." "This insulin can be mixed with short-acting insulin in a single syringe." "This type of insulin can be used in a pump." "This insulin has an increased risk for hypoglycemia." - This type of insulin should be given at the same time every day. A nurse is caring for a client who has an area indicating potential breakdown over the sacrum. Which of the following actions should the nurse take? Minimize the time the head of the bed is elevated. Apply a sterile gauze dressing to the site. Massage the site with moisturizing lotion. Place a donut-shaped cushion under the client's sacral area. - Minimize the time the head of the bed is elevated. A nurse is reinforcing teaching about the management of constipation with a client who has hypothyroidism. Which of the following instructions should the nurse include in the teaching? Increase intake of fiber-rich foods. Take a laxative every morning Maintain a fluid intake of 1,200 mL/day. Limit activity to preserve energy. • - Increase intake of fiber-rich foods. A nurse is reinforcing teaching with a client who is scheduled for a guaiac fecal occult blood test. Which of the following instructions should the nurse include in the teaching? Do not eat or drink for 6 hr prior to the test Ensure that the stool specimen is obtained in the morning. Take ibuprofen for mild pain until the test is complete. Avoid eating red meat for 3 days prior to the test. - Avoid eating red meat for 3 days prior to the test. A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse identify as the priority? Muscle weakness Dysrhythmia Abdominal pain Lethargy - Dysrhythmia A nurse is collecting data from a 55-year-old female client who reports vaginal dryness and hot ashes. The client is interested in trying hormone replacement therapy (HRT). Which of the following should the nurse recognize as a contraindication to HRT? Five-year history of menopause manifestations History of treatment for blood clots Topiramate use for migraine headaches Increased serum cholesterol levels - History of treatment for blood clots A nurse is caring for a client who is receiving chemotherapy. The client mentions that they have a loss of appetite because of sores in their mouth and that food no longer tastes good. Which of the following suggestions to the client should the nurse make? Drink water before and after each bite. Consume foods that are served hot rather than cold. Rinse with a glycerin-based mouthwash before meals. Eat several, small-portioned meals daily. - Eat several, small-portioned meals daily. A nurse is reinforcing discharge instructions with a client who is postoperative following a right hip arthroplasty. Which of the following statements should the nurse make? "You may cross your legs in 60 days." "Avoid lying on your operative side." "Avoid bending your hips more than 90 degrees." "You may sleep on a soft mattress." - "Avoid bending your hips more than 90 degrees." A nurse is caring for a client who is 1 day postoperative following a hip arthroplasty. The client is exhibiting hypotension, tachycardia, and tachypnea. The nurse should recognize that these findings indicate which of the following complications? Wound infection Pulmonary embolism Thrombophlebitis Paralytic ileus - Pulmonary embolism A nurse is reinforcing teaching with a client who has mitral valve disease. Which of the following statements by the client indicates an understanding of the disease process? "I should call my doctor if I get a headache." "I might develop gastric reux." "I might develop excessive bruising." "I should call my doctor if my ankles swell." • - "I should call my doctor if my ankles swell." A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an IV contrast agent. Which of the following laboratory findings should the nurse report to the provider prior to the procedure? Sodium 136 mEq/L Potassium 4.8 mEq/L Creatinine 1.9 mg/dL Calcium 10 mg/dL - Creatinine 1.9 mg/dL A nurse is contributing to the plan of care for a client who has COPD and is dyspneic. Which of the following interventions should the nurse include in the plan? Encourage abdominal breathing. Direct the client to inhale with pursed lips. Set the oxygen therapy at 5 L/min. Instruct the client to lean back when coughing. - Encourage abdominal breathing. A nurse is contributing to the plan of care for a client who has Ménière's disease. Which of the following interventions should the nurse include in the plan of care? Increase the client's fluid intake. Assist the client with changing positions often. Encourage the client to rest in a well-lit room. Administer an antiemetic to the client - Administer an antiemetic to the client A nurse is discussing health screening guidelines with an older adult client. Which of the following statements should the nurse include? "You should have a screening for glaucoma every 5 years." "You should have a physical examination every other year." "You should have your hearing checked every 2 years." "You should have a pneumococcal immunization every 10 years." - "You should have a pneumococcal immunization every 10 years." A nurse is preparing to remove a client's NG tube. Which of the following interventions should the nurse take to decrease the risk for aspiration? Instill 10 mL of air through the NG tube. Place the client in the supine position. Irrigate the NG tube. Pinch the NG tube. - Pinch the NG tube. A nurse is preparing to administer phytonadione 7 mg subcutaneously to a client who has an INR of 4. Available is phytonadione 10 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) - 0.7 A nurse is planning to implement droplet precautions for a client who has manifestations of pertussis. Which of the following interventions should the nurse include when contributing to the plan of care? Apply a mask on the client if the transport is needed. Wear a mask when working within 1.2 m (4 feet) of the client Don a gown when visiting with the client Wear an N95 mask when entering the client's room. - Apply a mask on the client if transport is needed. • A nurse is caring for a client who is in Buck's traction. Which of the following interventions should the nurse perform to reduce skin breakdown? Keep the skin dry and free of perspiration. Use hot water and antibacterial soap to bathe the client. Massage the skin over bony prominences to promote circulation. Limit the use of moisturizers on the skin over bony prominences. - Keep the skin dry and free of perspiration. A nurse is assisting a client who reports difficulty falling asleep. Which of the following activities should the nurse recommend to promote sleep? Get out of bed if unable to fall asleep within 60 min. Take a brisk walk before sleeping. Listen to soft music before sleeping. Drink adequate amounts of uids before sleeping. - Listen to soft music before sleeping. A nurse is caring for a client who has meningococcal pneumonia. Which of the following personal protective equipment should the nurse use? Gown Mask Sterile gloves Protective eyewear - Mask A nurse is performing an ECG on a client who is scheduled for surgery the following morning. In which of the following locations should the nurse place the V1 electrode? (You will nd hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.) - C is correct. The nurse should identify that the V1 electrode should be placed in the fourth intercostal space just to the right of the sternum. Correct placement of the electrodes is vital in obtaining accurate information about the electrical activity of the heart. A nurse enters the room of a client whose transfusion of packed RBCs was initiated 15 min ago by the RN. The client reports dyspnea and urticaria. After stopping the infusion, which of the following actions should the nurse take next? Collect a urine sample. Take the client's vital signs. Return the blood to the laboratory. Administer an antihistamine. - Take the client's vital signs. A nurse is preparing to suction a client who has a tracheostomy. Which of the following actions should the nurse take first? Insert the suction catheter into the tracheostomy Rinse the catheter with sterile 0.9% sodium chloride. Ventilate the client with 100% oxygen Occlude the vent on the catheter for 10 seconds - Ventilate the client with 100% oxygen A nurse is caring for a client who is scheduled for surgery and is experiencing anxiety. Which of the following interventions should the nurse identify as the priority? Determine the client's understanding of the procedure. Encourage the client to express their feelings. Allow the client's partner to stay with them. Provide music as a distraction. - Determine the client's understanding of the procedure. A nurse is caring for a client who reports stomatitis. Which of the following dietary recommendations should the nurse make? "Eat soft foods." "Season foods with salt." "Select foods that are low in protein." "Choose foods that are served hot." - "Eat soft foods."