ATI PN Med Surg
Study online at https://quizlet.com/_fe2jur
1. 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?: Herpes
zoster
Rationale:
The nurse should recommend the herpes zoster vaccine for adults who are 60 years
of age and older.
--------------
The nurse should recommend the meningococcal vaccine to college students and
military recruits who are living in shared housing.
The nurse should recommend the HPV vaccine for clients who are 9 to 26 years of
age.
The nurse should recommend the MMR vaccine to clients who are 62 years of age.
2. 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 procedures?: Creatinine 1.9
mg/dL
Rationale:
Creatinine 1.9 mg/dL is not within the expected reference range. Therefore, the nurse
should report the finding to the provider before the client has a CT scan with an IV
contrast agent. This finding places the client at risk for developing contrast-induced
nephropathy.
---------------------
Expected ranges:
Calcium (ca) 9 - 10.5 mg/dL
Sodium (Na) 136 - 145 mEq/L
Potassium (K) 3.5 - 5 mEq/L
3. A nurse is reinforcing teaching about home care with a client who had knee
arthroplasty. Which of the following factors should the nurse identify as an
indication that a barrier to learning might be present?: The client stops the nurse
and asks for pain medication
Rationale:
, ATI PN Med Surg
Study online at https://quizlet.com/_fe2jur
The nurse should identify that a client who is in pain will not be able to concentrate,
which can interfere with their ability to learn.
4. A nurse is caring for a client who has a acute ischemic stroke 1 day ago.
Which of the following actions should the nurse take to reduce the risk for
aspirations?: Allow for 30 min of rest before meals.
Rationale:
The nurse should allow the client to rest for 30 min before meals to prevent
aspiration.
5. 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?: Encourage the client to com-
plete ADLs.
Rationale:
The nurse should encourage the client to complete ADLs and provide assistance
as needed. Performing self-care increases the client's independence, strength, and
level of functioning.
6. A nurse is reinforcing about joint protection with a clietn who has an
acute exacerbation of rheumatoid arthritis. Which of the following information
should the nurse include in the teaching?: Apply cold packs to the inflamed joints
Rationale: The nurse should instruct the client to use both warm and cold packs on
inflamed joints to decrease pain.
-----------------
The nurse should instruct the client to participate in low-impact aerobic exercises,
which will not inflame the client's joints.
The nurse should instruct the client to carry a shoulder bag, which places the stress
on larger muscles.
The nurse should instruct the client to sleep on a firm mattress to support their joints.
7. A nurse is caring for a client who is schedules for surgery and is experienc-
ing anxiety. Which of the following interventions should the nurse identify as
the priority?: Determine the client's understanding of the procedure.
Rationale: When using the nursing process, the first action the nurse should take
is to collect data from the client. Therefore, the nurse should determine the client's
, ATI PN Med Surg
Study online at https://quizlet.com/_fe2jur
understanding of the procedure to reinforce necessary teaching, which can help
manage their anxiety.
8. A nurse is caring for a client who reports stomatitis. Which of the following
dietary recommendations should the nurse make?: Eat soft foods.
Rationale:
The nurse should instruct a client who has stomatitis to eat soft, nonirritating foods
to decrease irritation to the oral mucosa.
-----------------
Instruct the client to avoid seasoning foods with salt or spices that can irritate the
oral mucosa.
Instruct the client to eat foods that are high in protein and calories to increase their
caloric intake and nutrition.
Instruct the client to choose foods that are a lukewarm or cool temperature to prevent
irritation of the client's oral mucosa.
9. A nurse is planning to implement droplet precautions for a client who has
manifestations of pertussis. Which of teh following interventions should the
nurse include when contributing to the plan of care?: Apply a mask on the client
if transport is needed.
Raitonale:
The nurse should apply a mask to a client who has manifestations of pertussis during
transport to prevent exposure to others.
10. A nurse is assisting a client who reports difficulty falling asleep. Which of
the following activities should the nurse recommend to promote sleep?: Listen
to soft music before sleeping.
Rationale:
Listening to soft music can help the client to relax and reduces environmental
stressors.
11. A nurse is contributing to the plan of care for a client who is having difficul-
ty eating following a stroke. Which of the following actions should the nurse
take first?: Implement recommendation from the speech language pathologist.
Rationale:
The greatest risk to the client following a stroke is injury from aspiration. Therefore,
, ATI PN Med Surg
Study online at https://quizlet.com/_fe2jur
the first intervention the nurse should include in the plan of care is to imple-
ment recommendations from the speech language pathologist. A speech language
pathologist can conduct a swallow study to determine the client's risk for aspiration,
provide teaching to the client regarding swallowing techniques, and recommend the
consistency of foods and liquids for the client.
12. A nurse is assisting in the plan of care regarding bowel retraining for a
client who has acervical spinal cord injury. Which of the following interven-
tions should the nurse plan to implement first?: Determine the client's daily
elimination habits.
Rationale:
The first action the nurse should take when using the nursing process is to collect
data on the client's daily bowel elimination habits to establish a routine defecation
time.
13. 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.
Rationale:
A mechanical bowel obstruction prevents a portion or all of the bowel contents
from moving forward through the bowel. The nurse should expect to auscultate
high-pitched, hyperactive bowel sounds above the point of the intestinal obstruction
as the intestines attempt to propel the blockage forward.
14. A nurse is assisting with the care of a client who has a newly-inserted
closed chest tube. Which of the following findings should the nurse report to
the provider?: Chest drainage is greater than 70 mL/hr
Rationale:
The nurse should identify that chest drainage of greater the 70 mL/hr can indicate
a complication and should be reported to the provider.
15. 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?: Keep the cleint in a
side-lying position.
Rationale:
The greatest risk to the client following a stroke is aspiration. The nurse should
position the client in a lateral, or side-lying, position to allow any secretions to drain
Study online at https://quizlet.com/_fe2jur
1. 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?: Herpes
zoster
Rationale:
The nurse should recommend the herpes zoster vaccine for adults who are 60 years
of age and older.
--------------
The nurse should recommend the meningococcal vaccine to college students and
military recruits who are living in shared housing.
The nurse should recommend the HPV vaccine for clients who are 9 to 26 years of
age.
The nurse should recommend the MMR vaccine to clients who are 62 years of age.
2. 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 procedures?: Creatinine 1.9
mg/dL
Rationale:
Creatinine 1.9 mg/dL is not within the expected reference range. Therefore, the nurse
should report the finding to the provider before the client has a CT scan with an IV
contrast agent. This finding places the client at risk for developing contrast-induced
nephropathy.
---------------------
Expected ranges:
Calcium (ca) 9 - 10.5 mg/dL
Sodium (Na) 136 - 145 mEq/L
Potassium (K) 3.5 - 5 mEq/L
3. A nurse is reinforcing teaching about home care with a client who had knee
arthroplasty. Which of the following factors should the nurse identify as an
indication that a barrier to learning might be present?: The client stops the nurse
and asks for pain medication
Rationale:
, ATI PN Med Surg
Study online at https://quizlet.com/_fe2jur
The nurse should identify that a client who is in pain will not be able to concentrate,
which can interfere with their ability to learn.
4. A nurse is caring for a client who has a acute ischemic stroke 1 day ago.
Which of the following actions should the nurse take to reduce the risk for
aspirations?: Allow for 30 min of rest before meals.
Rationale:
The nurse should allow the client to rest for 30 min before meals to prevent
aspiration.
5. 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?: Encourage the client to com-
plete ADLs.
Rationale:
The nurse should encourage the client to complete ADLs and provide assistance
as needed. Performing self-care increases the client's independence, strength, and
level of functioning.
6. A nurse is reinforcing about joint protection with a clietn who has an
acute exacerbation of rheumatoid arthritis. Which of the following information
should the nurse include in the teaching?: Apply cold packs to the inflamed joints
Rationale: The nurse should instruct the client to use both warm and cold packs on
inflamed joints to decrease pain.
-----------------
The nurse should instruct the client to participate in low-impact aerobic exercises,
which will not inflame the client's joints.
The nurse should instruct the client to carry a shoulder bag, which places the stress
on larger muscles.
The nurse should instruct the client to sleep on a firm mattress to support their joints.
7. A nurse is caring for a client who is schedules for surgery and is experienc-
ing anxiety. Which of the following interventions should the nurse identify as
the priority?: Determine the client's understanding of the procedure.
Rationale: When using the nursing process, the first action the nurse should take
is to collect data from the client. Therefore, the nurse should determine the client's
, ATI PN Med Surg
Study online at https://quizlet.com/_fe2jur
understanding of the procedure to reinforce necessary teaching, which can help
manage their anxiety.
8. A nurse is caring for a client who reports stomatitis. Which of the following
dietary recommendations should the nurse make?: Eat soft foods.
Rationale:
The nurse should instruct a client who has stomatitis to eat soft, nonirritating foods
to decrease irritation to the oral mucosa.
-----------------
Instruct the client to avoid seasoning foods with salt or spices that can irritate the
oral mucosa.
Instruct the client to eat foods that are high in protein and calories to increase their
caloric intake and nutrition.
Instruct the client to choose foods that are a lukewarm or cool temperature to prevent
irritation of the client's oral mucosa.
9. A nurse is planning to implement droplet precautions for a client who has
manifestations of pertussis. Which of teh following interventions should the
nurse include when contributing to the plan of care?: Apply a mask on the client
if transport is needed.
Raitonale:
The nurse should apply a mask to a client who has manifestations of pertussis during
transport to prevent exposure to others.
10. A nurse is assisting a client who reports difficulty falling asleep. Which of
the following activities should the nurse recommend to promote sleep?: Listen
to soft music before sleeping.
Rationale:
Listening to soft music can help the client to relax and reduces environmental
stressors.
11. A nurse is contributing to the plan of care for a client who is having difficul-
ty eating following a stroke. Which of the following actions should the nurse
take first?: Implement recommendation from the speech language pathologist.
Rationale:
The greatest risk to the client following a stroke is injury from aspiration. Therefore,
, ATI PN Med Surg
Study online at https://quizlet.com/_fe2jur
the first intervention the nurse should include in the plan of care is to imple-
ment recommendations from the speech language pathologist. A speech language
pathologist can conduct a swallow study to determine the client's risk for aspiration,
provide teaching to the client regarding swallowing techniques, and recommend the
consistency of foods and liquids for the client.
12. A nurse is assisting in the plan of care regarding bowel retraining for a
client who has acervical spinal cord injury. Which of the following interven-
tions should the nurse plan to implement first?: Determine the client's daily
elimination habits.
Rationale:
The first action the nurse should take when using the nursing process is to collect
data on the client's daily bowel elimination habits to establish a routine defecation
time.
13. 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.
Rationale:
A mechanical bowel obstruction prevents a portion or all of the bowel contents
from moving forward through the bowel. The nurse should expect to auscultate
high-pitched, hyperactive bowel sounds above the point of the intestinal obstruction
as the intestines attempt to propel the blockage forward.
14. A nurse is assisting with the care of a client who has a newly-inserted
closed chest tube. Which of the following findings should the nurse report to
the provider?: Chest drainage is greater than 70 mL/hr
Rationale:
The nurse should identify that chest drainage of greater the 70 mL/hr can indicate
a complication and should be reported to the provider.
15. 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?: Keep the cleint in a
side-lying position.
Rationale:
The greatest risk to the client following a stroke is aspiration. The nurse should
position the client in a lateral, or side-lying, position to allow any secretions to drain
