Ati rn medical surgical proctored
A home health nurse is caring for a client who has COPD. The client tells the nurse
that he becomes short of breath while eating despite the use of home oxygen. What
instructions should the nurse include? - ansDrink beverages at the end of meals
A home health nurse is reinforcing teaching with a client about preventing
complications of peripheral vascular disease. What statement by the client indicates
that they are adhering to the nurse's instructions? - ans"I don't cross my legs
anymore".
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. What action should
the nurse perform first? - ansStop the infusion
A nurse in an orthopedic clinic is reinforcing teaching with a client who has
osteoarthritis. What instructions should the nurse include to promote comfort? -
ansSleep on a firm mattress
A nurse is admitting a client who is suspected having active tuberculosis (TB). What
action should should the nurse take first? - ansInstitute airborne precautions
A nurse is assisting in the care of a client who has manifestations of sepsis. What
provider prescriptions should the nurse implement first? - ansInitiate oxygen at 4
L/min via nasal cannula
A nurse is assisting in the plan of care for a client who has a recent left hemispheric
stroke. What action should the nurse include in the plan? - ansUse simple verbal
cues when directing tasks
A nurse is assisting with an educational program for clients who have newly
diagnosed with diabetes mellitus. What instruction should the nurse include in the
program regarding insulin? - ansOpened insulin can be stored on a cool countertop
away from light
A nurse is caring for a client following a gastrectomy. What action should the nurse
take to decrease episodes of dumping syndrome? - ansPlace the client in the supine
position after meals
A nurse is caring for a client who has a methicillin-resistant Staphlococcus aureus
(MRSA) infections in a surgical wound. What information should the nurse plan to
share with visitors? - ansVisitors must don a gown & gloves prior to entering the
client's room.
A nurse is caring for a client who has a new cast on her left forearm and report
severe pain in the affected arm with numbness in the fingers. The nurse finds the
skin is pale and cold with sluggish capillary refill. What fracture complication should
the nurse suspect? - ansCompartment syndrome
,Ati rn medical surgical proctored
A nurse is caring for a client who has a prescription for digoxin 0.25mg PO daily.
While taking the client's apical pulse, the nurse notes a rate of 58/ min. What action
should the nurse take? - ansWithhold the dose
A nurse is caring for a client who has an intestinal obstruction & reports a new onset
of nausea. The client has an NG tube set at low intermittent suction & is receiving
continuous IV infusion of 0.9% sodium chloride. What action should the nurse take
first?
- ansCheck for kinks in the NG tube
A nurse is caring for a client who has dementia due to Alzheimer's disease. What
action should the nurse take to reduce the client's confusion? - ansEncourage
reminiscence of past experiences
A nurse is caring for a client who has meningococal pneumonia. Which of the
following personal protective equipment should the nurse use? - ansMask (this
disease requires droplet precautions)
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." What response should the nurse make? -
ans"Tell me more about the way you are feeling."
A nurse is caring for a client who is 1 day post operative following a hip
arthroplasty. The client is exhibiting hypotension, tachycardia, & tacky-nearly. The
nurse should recognize these findings as what complication? - ansPulmonary
Embolism
A nurse is caring for a client who is 24hr postoperative following abdominal surgery
& has an NG tube. What action should the nurse plan to take to decrease the risk of
postoperative complications? - ansEncourage the client to use an incentive
spirometer every hour while awake
A nurse is caring for a client who is 24hr postoperative following an abdominal
surgery. What finding requires immediate attention from the nurse? - ansOxygen
saturation of 88%
A nurse is caring for a client who is in Buck's traction. What intervention should the
nurse perform to reduce skin breakdown? - ansKeep the skin dry and free of
perspiration
A nurse is caring for a client who is post operative following a transurethral
resection of the prostate (TURP) and is receiving continuous bladder irrigation. The
nurse notes decreased output from the urethral catheter. What prescription should
the nurse expect the provider to order? - ansIrrigate the urethral catheter with 0.9%
sodium chloride
A nurse is caring for a client who reports shortness of breath and has an oxygen
saturation of 90%. What action should the nurse take? - ansAdminister oxygen via
nasal cannula
, Ati rn medical surgical proctored
A nurse is caring for a female client who is being treated for dehydration due to
nausea & vomiting. What finding should the nurse report to the provider? - ansHeart
rate 120/ min
A nurse is caring for four clients. What conditions should the nurse identify as a risk
for developing vascular disease? - ansDiabetes mellitus
A nurse is collecting data from a client who has chronic kidney disease with
hyperkalemia. What finding should the nurse expect related to hyperkalemia? -
ansBradycardia
A nurse is collecting data from a client who has hypokalemia. What finding should
the nurse identify as the priority? - ansDysrhythmia
A nurse is collecting data from a client who has hypothyroidism. What manifestation
should the nurse expect? - ansBradycardia
A nurse is contributing to the plan of care for a client who has a methicillin-resistant
Staphylococcus aureus (MRSA) infections and is on contract isolation precautions.
What action should the nurse take? - ansHave a designated stethoscope in the
client's room
A nurse is contributing to the plan of care for a client who has just transferred to
the medical-surgical unit from PACU following a right total knee arthroplasty.
What interventions should the nurse include in the plan? - ansAssist the client
to change position every 2hr
A nurse is contributing to the plan of care for a client who has pericarditis. What
position should the nurse plan to place the client to decrease plan? - ansUpright,
leaning forward
A nurse is contributing to the plan of care for a client who has tuberculosis (TB).
What intervention should the nurse include? - ansPlace the client in a negative
pressure airflow room
A nurse is contributing to the plan of care for an older adult client who is at risk for
Osteoporosis. Which intervention should the nurse include to prevent bone loss? -
ansEncourage weight bearing exercises (such as walking because it can help
maintain bone mass by reducing bone demineralization, thus helping to prevent
osteoporosis.)
A nurse is monitoring a client who has a wrist cast and reports intense itching
underneath the cast. What action should the nurse take? - ansBlow cool air into the
cast using a blow dryer on a cool setting
A home health nurse is caring for a client who has COPD. The client tells the nurse
that he becomes short of breath while eating despite the use of home oxygen. What
instructions should the nurse include? - ansDrink beverages at the end of meals
A home health nurse is reinforcing teaching with a client about preventing
complications of peripheral vascular disease. What statement by the client indicates
that they are adhering to the nurse's instructions? - ans"I don't cross my legs
anymore".
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. What action should
the nurse perform first? - ansStop the infusion
A nurse in an orthopedic clinic is reinforcing teaching with a client who has
osteoarthritis. What instructions should the nurse include to promote comfort? -
ansSleep on a firm mattress
A nurse is admitting a client who is suspected having active tuberculosis (TB). What
action should should the nurse take first? - ansInstitute airborne precautions
A nurse is assisting in the care of a client who has manifestations of sepsis. What
provider prescriptions should the nurse implement first? - ansInitiate oxygen at 4
L/min via nasal cannula
A nurse is assisting in the plan of care for a client who has a recent left hemispheric
stroke. What action should the nurse include in the plan? - ansUse simple verbal
cues when directing tasks
A nurse is assisting with an educational program for clients who have newly
diagnosed with diabetes mellitus. What instruction should the nurse include in the
program regarding insulin? - ansOpened insulin can be stored on a cool countertop
away from light
A nurse is caring for a client following a gastrectomy. What action should the nurse
take to decrease episodes of dumping syndrome? - ansPlace the client in the supine
position after meals
A nurse is caring for a client who has a methicillin-resistant Staphlococcus aureus
(MRSA) infections in a surgical wound. What information should the nurse plan to
share with visitors? - ansVisitors must don a gown & gloves prior to entering the
client's room.
A nurse is caring for a client who has a new cast on her left forearm and report
severe pain in the affected arm with numbness in the fingers. The nurse finds the
skin is pale and cold with sluggish capillary refill. What fracture complication should
the nurse suspect? - ansCompartment syndrome
,Ati rn medical surgical proctored
A nurse is caring for a client who has a prescription for digoxin 0.25mg PO daily.
While taking the client's apical pulse, the nurse notes a rate of 58/ min. What action
should the nurse take? - ansWithhold the dose
A nurse is caring for a client who has an intestinal obstruction & reports a new onset
of nausea. The client has an NG tube set at low intermittent suction & is receiving
continuous IV infusion of 0.9% sodium chloride. What action should the nurse take
first?
- ansCheck for kinks in the NG tube
A nurse is caring for a client who has dementia due to Alzheimer's disease. What
action should the nurse take to reduce the client's confusion? - ansEncourage
reminiscence of past experiences
A nurse is caring for a client who has meningococal pneumonia. Which of the
following personal protective equipment should the nurse use? - ansMask (this
disease requires droplet precautions)
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." What response should the nurse make? -
ans"Tell me more about the way you are feeling."
A nurse is caring for a client who is 1 day post operative following a hip
arthroplasty. The client is exhibiting hypotension, tachycardia, & tacky-nearly. The
nurse should recognize these findings as what complication? - ansPulmonary
Embolism
A nurse is caring for a client who is 24hr postoperative following abdominal surgery
& has an NG tube. What action should the nurse plan to take to decrease the risk of
postoperative complications? - ansEncourage the client to use an incentive
spirometer every hour while awake
A nurse is caring for a client who is 24hr postoperative following an abdominal
surgery. What finding requires immediate attention from the nurse? - ansOxygen
saturation of 88%
A nurse is caring for a client who is in Buck's traction. What intervention should the
nurse perform to reduce skin breakdown? - ansKeep the skin dry and free of
perspiration
A nurse is caring for a client who is post operative following a transurethral
resection of the prostate (TURP) and is receiving continuous bladder irrigation. The
nurse notes decreased output from the urethral catheter. What prescription should
the nurse expect the provider to order? - ansIrrigate the urethral catheter with 0.9%
sodium chloride
A nurse is caring for a client who reports shortness of breath and has an oxygen
saturation of 90%. What action should the nurse take? - ansAdminister oxygen via
nasal cannula
, Ati rn medical surgical proctored
A nurse is caring for a female client who is being treated for dehydration due to
nausea & vomiting. What finding should the nurse report to the provider? - ansHeart
rate 120/ min
A nurse is caring for four clients. What conditions should the nurse identify as a risk
for developing vascular disease? - ansDiabetes mellitus
A nurse is collecting data from a client who has chronic kidney disease with
hyperkalemia. What finding should the nurse expect related to hyperkalemia? -
ansBradycardia
A nurse is collecting data from a client who has hypokalemia. What finding should
the nurse identify as the priority? - ansDysrhythmia
A nurse is collecting data from a client who has hypothyroidism. What manifestation
should the nurse expect? - ansBradycardia
A nurse is contributing to the plan of care for a client who has a methicillin-resistant
Staphylococcus aureus (MRSA) infections and is on contract isolation precautions.
What action should the nurse take? - ansHave a designated stethoscope in the
client's room
A nurse is contributing to the plan of care for a client who has just transferred to
the medical-surgical unit from PACU following a right total knee arthroplasty.
What interventions should the nurse include in the plan? - ansAssist the client
to change position every 2hr
A nurse is contributing to the plan of care for a client who has pericarditis. What
position should the nurse plan to place the client to decrease plan? - ansUpright,
leaning forward
A nurse is contributing to the plan of care for a client who has tuberculosis (TB).
What intervention should the nurse include? - ansPlace the client in a negative
pressure airflow room
A nurse is contributing to the plan of care for an older adult client who is at risk for
Osteoporosis. Which intervention should the nurse include to prevent bone loss? -
ansEncourage weight bearing exercises (such as walking because it can help
maintain bone mass by reducing bone demineralization, thus helping to prevent
osteoporosis.)
A nurse is monitoring a client who has a wrist cast and reports intense itching
underneath the cast. What action should the nurse take? - ansBlow cool air into the
cast using a blow dryer on a cool setting
