med surg 1 ATI /100 questions proctored exam Correctly Solved

A nurse in an emergency department is preparing to perform an ocular irrigation for a client. Which of the following actions should the nurse plan to take? a. Assess the client's visual acuity prior to irrigation b. Have the client turn their head toward the unaffected eye c. Hold the irrigator syringe 3.81 cm (1.5 in) above the eye d. Perform the irrigation with sterile water for irrigation - ANSWER d. Perform the irrigation with sterile water for irrigation A nurse is preparing to administer lactated ringer's via continuous IV infusion at 200 ml/hr. The IV tubing has a drop factor of 10 drops/ml. How many gtt/min should the nurse set the IV pump to administer? Round to near whole number - ANSWER 33 gtt/min A nurse is providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following client statements indicates an understanding of the teaching? a. I can keep my medications for 1 year before replacing it b. I should lie down when I take this medication c. I should discontinue this medication if I develop a headache d. I can take up to five tablets in 15 minutes before seeking medical attention - ANSWER b. I should lie down when I take this medication A nurse is providing discharge teaching to an older adult client following a left total hip arthroplasty. Which of the following instructions should the nurse include in the teaching? a. Clean the incision daily with hydrogen peroxide b. You can cross your legs the ankles when sitting down c. You should use an incentive spirometer every 8 hours d. Install a raised toilet seat in your bathroom - ANSWER d. Install a raised toilet seat in your bathroom A nurse is planning care for a client following a cardiac catheterization. Which of the following actions should the nurse take? a. Keep the client on bed rest for 24 hours b. Limit the client's fluid intake to 1 l per day c. Maintain the client's affected extremity in extension d. Change the client's dressing every 8 hour - ANSWER c. Maintain the client's affected extremity in extension A nurse is caring for a client who has a lower extremity fracture and a prescription for crutches. Which of the following client statements indicates that the client is adapting to their role change? a. I will need to have my partner take over shopping for groceries and cooking the meals for us b. These crutches will make it impossible to care for my child c. I feel bad that I have to ask my partner to keep the house clean d. Its going to be difficult to tell my parents I cant take them to their appointments anymore - ANSWER a. I will need to have my partner take over shopping for groceries and cooking the meals for us A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration? a. Pitting, dependent edema b. Distended jugular veins c. Increased BP d. Decreased BP - ANSWER d. Decreased BP A nurse is caring for a client who has a contusion of the brainstem and reports thirst. The client's urinary output was 4,000 ml over the past 24 hour. The nurse should anticipate a prescription for which of the following IV medication? a. Desmopressin b. Epinephrine c. Furosemide d. Nitroprusside - ANSWER a. Desmopressin A nurse in a clinic receives a phone call from a client who recently started therapy with an ACE inhibitor and reports a nagging dry cough. Which of the following responses by the nurse is appropriate? a. "your cough may require that you stop or change your medication" b. "Increasing your daily fluid intake may eliminate your cough" c. "sucking on lozenge may reduce the frequency of your cough" d. You cough should go away in time" - ANSWER a. "your cough may require that you stop or change your medication" A nurse is taking an admission history from a client who reports Raynaud's disease. Which of the following assessment findings should the nurse identify as a potential trigger for exacerbations of Raynaud's? a. Eating a strict vegetarian diet b. A history of herpes zoster c. Taking amiodipine for hypertension d. Using a nicotine transdermal patch - ANSWER d. Using a nicotine transdermal patch A nurse is caring for a client who has a central venous access device and notes the tubing has become disconnected. The client develops dyspnea and tachycardia. Which of the following actions should the nurse take first? a. Perform an ECG b. Obtain ABG values c. Turn the client to his left side d. Clamp the catheter - ANSWER d. Clamp the catheter A nurse is completing an assessment of an older adult client and notes reddened areas over the bony prominences, but the client's skin is intact. Which of the following interventions should the nurse include in the plan of care? a. Turn and reposition the client every 4 hr b. Apply an occlusive dressing c. Support bony prominences with pillows d. Massage the reddened areas three times a day - ANSWER c. Support bony prominences with pillows A home health nurse is making an initial visit to a client who has multiple sclerosis. Which of the following actions is the priority for the nurse to take? a. Discuss recommendations for eating and swallowing techniques b. List strategies for family coping when dealing with possible role changes c. Review the use of adaptive grooming devices to promote client independence d. Give the client information about the local national multiple sclerosis society - ANSWER a. Discuss recommendations for eating and swallowing techniques A nurse in the emergency department is assessing a client. Which of the following actions should the nurse take first? Exhibit a. Obtain a sputum sample for culture b. Administer ondansetron c. Initiate airborne precautions d. Prepare the client for a chest x-ray - ANSWER c. Initiate airborne precautions A nurse is reviewing the medical record of a client to identify risk factors for colorectal cancer. The nurse should identify which of the following findings as increasing the client's risk? a. History of Crohn's disease b. BMI of 24 c. Diet high in fiber d. Age 46 years - ANSWER a. History of Crohn's disease A nurse is caring for a client who is scheduled for a mastectomy. The client tells the nurse, "I'm not sure I want to have a mastectomy." Which of the following statements should the nurse make? a. "I can give you a list of other people who had the same procedure" b. "You will be cancer-free if you have the procedure" c. "I can give you additional information about the procedure" d. "You should should get a second opinion regarding the procedure" - ANSWER c. "I can give you additional information about the procedure" A nurse is preparing to administer a unit of packed RBCs to a client who is anemic. Identify the sequence of steps the nurse should follow. e. Remain with the client for the first 15 to 30 min of the infusion a. Obtain venous access using 19-gauge needle c. Verify blood compatibility with another nurse d. Initiate transfusion of the unit of packed RBCs b. Obtain the unit of packed RBCs from blood bank - ANSWER a. Obtain venous access using 19-gauge needle b. Obtain the unit of packed RBCs from blood bank c. Verify blood compatibility with another nurse d. Initiate transfusion of the unit of packed RBCs e. Remain with the client for the first 15 to 30 min of the infusion A nurse is preparing a teaching plan for a client who has mucositis related to chemotherapy treatment. Which of the following instructions should the nurse include? a. "rinse your mouth with hydrogen peroxide" b. "brush your teeth for 60 seconds twice daily" c. "wear your dentures only during meals" d. "floss your teeth following each meals" - ANSWER d. "floss your teeth following each meals" A critical care nurse is assessing a client who has severe head injury. In response to painful stimuli, the client does not open her eyes, displays decerebrate posturing, and makes incomprehensible sounds. Which of the following Glasgow Coma Scale scores should the nurse assign the client? a. 5 b. 2 c. 13 d. 10 - ANSWER a. 5 A nurse is providing discharge teaching to a client who has heart failure and instructs him to limit sodium intake to 2 g per day. Which of the following statements by the client indicates an understanding of the teaching? a. "I can season my foods with garlic and onion salts" b. "I can have mayonnaise on my sandwiches" c. "I can have a frozen fruit juice bar for dessert" d. "I can drink vegetable juice with a meal" - ANSWER c. "I can have a frozen fruit juice bar for dessert" A nurse is preparing to perform ocular irrigation for a client following chemical splash to the eye. Which of the following actions should the nurse plan to take first? a. Instill 0.9% sodium chloride solution into the affected eye b. Administer proparacaine eyedrops into the affected eye c. Collect information about the irritant that caused the injury - ANSWER c. Collect information about the irritant that caused the injury A nurse is assessing a client following extubation from a ventilator. For which of the following findings should the nurse intervene immediately? a. Rhonchi b. SaO2 92% c. Sore throat d. Stridor - ANSWER d. Stridor A nurse is reviewing the laboratory reports of a client who has acute pancreatitis. Which of the following findings should the nurse expect? a. Elevated serum calcium b. Elevated blood glucose c. Decreased serum amylase d. Decreased erythrocyte sedimentation rate - ANSWER b. Elevated blood glucose A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of the following findings should the nurse expect? a. Hypothermia b. Urine specific gravity 1.001 (1.005) c. Elevated blood pressure d. BUN 15 mg/dl - ANSWER b. Urine specific gravity 1.001 (1.005) A nurse is planning care for a client who has pulmonary embolism. Which of the following interventions should the nurse include? a. Initiate a continuous IV heparin infusion b. Instruct the client to massage the lower extremities c. Position the client on the left side d. Measure vital signs every 4 hour - ANSWER a. Initiate a continuous IV heparin infusion A nurse is providing discharge teaching to a client who is recovering from a sickle cell crisis. Which of the following instructions should the nurse include? a. Avoid extremely hot or cold temperatures b. Limit fluids to 1.5 L per day c. Limit alcohol intake to one drink per day d. Avoid getting a flu vaccination - ANSWER a. Avoid extremely hot or cold temperatures A nurse in the emergency department is caring for a client who is in hypovolemic shock. Which of the following actions should the nurse take first? a. Obtain a blood specimen for type and crossmatch b. Insert a large-bore IV catheter c. Administer IV therapy d. Monitor urine output - ANSWER b. Insert a large-bore IV catheter A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft? a. Dilated appearance of the graft b. Absence of a bruit c. Normotensive blood pressure d. Palpable thrill - ANSWER d. Palpable thrill A nurse is assessing a client who has heart failure and is receiving a loop diuretic. Which of the following findings indicates hypokalemia? a. Oliguria b. Hypertension c. Muscle weakness d. Positive chvostek's sign (CHEEK) - ANSWER c. Muscle weakness A nurse is caring for a client who has a full-thickness burn injury covering 15% of their body. Which of the following actions should the nurse take? a. Weigh the client once per week b. Provide the client with a protein intake of 1g/kg/day c. Maintain a daily count of the client's calorie intake d. Place the client on a low-carb diet - ANSWER c. Maintain a daily count of the client's calorie intake A nurse is providing discharge teaching to a client who has an ileostomy. Which of the following client statements indicates an understanding of the teaching? a. "I will expect my stools to be loose" b. "I will eat a high fiber diet' c. "I will take a laxative when I'm constipated" d. "I will empty my bag when it is full" - ANSWER a. "I will expect my stools to be loose" A nurse is caring for a client who is receiving total parental nutrition through a central line. The current bag is nearly empty, and a new bag is unavailable from the pharmacy. Which of the following actions should the nurse take? a. Switch the infusion to a 10% dextrose solution b. Discontinue the infusion and flush the line c. Decrease the rate of infusion to last until the new bag is available d. Start an infusion of 0.45% sodium chloride solution - ANSWER a. Switch the infusion to a 10% dextrose solution A nurse is caring for a client who is 6 hr postoperative following a thyroidectomy. The client reports tingling and numbness in the hands. The nurse should identify this as a sign of which of the following electrolyte imbalances? a. Hypocalcemia b. Hypokalemia c. Hypermagnesemia d. Hypernatremia - ANSWER a. Hypocalcemia A nurse is caring for a client who is caregiver for a relative who has chronic disease. Which of the following statements indicates the client is adapting to the role change? a. "I had to reschedule my doctor's appointment last week" b. "I have lunch with my friends once a week" c. "I've lost 15 pounds in the past 2 months" d. "I need to get my blood pressure medicine refilled" - ANSWER d. "I need to get my blood pressure medicine refilled" A nurse is reviewing medications taken at home with a client who has angina. Which of the following statements by the client indicates an understanding of the teaching?