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ATI Med-Surg Ch. 26-
A nurse in the emergency department is assessing a client who was in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, hear rate 124/min, respiratory rate 38/min, temperature 38.6C (101/4F), and SaO2 92% on room air. Which of the following actions should the nurse take first? - Administer oxygen via a high-flow mask A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome. Which of the following statements by the newly licensed nurse indicates understanding of the teaching? - "This medication is given to facilitate ventilation." A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome (ARDS)? - A client who experienced a near-drowning incident A client following coronary artery bypass graft surgery A client who has dysphagia A client who experienced a drug overdose A nurse is planning care for a client who has severe acute respiratory distress syndrome (SARS). Which of the following should be included in the plan of care for this client? - Providing supplemental oxygen Administration of bronchodilators Maintaining ventilatory support A nurse is caring for a client who is receiving vecuronium for acute respiratory distress syndrome (ARDS). Which of the following medications should the nurse anticipate administering with this medication? - Fentanyl Midazolam A nurse is orienting a newly licensed nurse on the care of a client who is receiving hemodynamic monitoring. Which of the following statements by the newly licensed nurse indicates the teaching was effective? - "A chest x-ray is needed to verify placement."
A nurse is caring for a client following a coronary artery bypass graft (CABG). Hemodynamic monitoring has been initiated. Which of the following actions by the nurse facilitate correct monitoring readings? - Level transducer to phlebostatic axis Zero transducer to room air Observe trends in readings Compare readings to physical assessment A nurse is caring for a client who is receiving hemodynamic monitoring and has the following hemodynamic readings: PAS 34 mm Hg, PAD 21 mm Hg, PAWP 16 mm Hg, and CVP 12 mm Hg. For which of the following is the client at risk? - Heart failure Cor pulmonale Pulmonary hypertension Peripheral edema A nurse is teaching a client the importance of remaining still following angiography. Which of the following is an appropriate statement by the nurse? - "Too much activity places you at risk for bleeding." A nurse is reviewing a new prescription to administer 0.9% sodium chloride IV at 50 mL/hr to a client who is receiving hemodynamic monitoring and has an indwelling IV catheter in the left hand. Which of the following sites can be used for administering this solution? - Peripheral saline lock Port on proximal (CVP) lumen of pulmonary artery (PA) catheter A nurse on a cardiac unit is caring for a group of clients. The nurse should recognize which of the following clients as being at risk for the development of a dysrhythmia? - A client who has metabolic alkalosis A client who has COPD A client who underwent stent placement in a coronary artery A nurse working on a cardiac unit is admitting a client who is to undergo a cardioversion and is reviewing the health record. Which of the following data requires that the nurse notify the provider to cancel the procedure? Mar: Ferrous Sulfate 200 mg PO 0800 and 2000, Diazepam 2 mg PO 0800 and 2000, Isosorbide 2.5 mg PO 4x a day AC and HS
A nurse is completing discharge teaching with a client who has a permanent pacemaker. Which of the following statements by the client indicates a need for further teaching? - "I will have to disconnect my garage door opener." A cardiac nurse educator is reviewing the use of the fixed rate mode pacemaker with a group of newly hired nurses. Which of the following statements by a newly hired nurse indicates understanding of the review? - "This means the pacemaker fires in an asynchronous pattern." A nurse is caring for a client who is 4 hr postoperative following coronary artery bypass grafting (CABG) surgery. He is able to inspire 200 mL with the incentive spirometer, then refuses to cough because he is tired and it hurts too much. Which of the following is an appropriate nursing intervention? - Administer IV bolus analgesic, and return in 15 min. A nurse is caring for a client following peripheral bypass graft surgery of the left lower extremity. Which of the following client findings pose an immediate concern? - Capillary refill of affected limb of 6 seconds Mottled appearance of the limb A nurse educator is reviewing the use of cardiopulmonary bypass during surgery for coronary artery bypass grafting with a croup of nurses. Which of the following should be included in the discussion? - The client's demand for oxygen is lowered Motion of the heart ceases Rewarming of the client takes place A nurse is caring for a client following an angioplasty that was inserted through the femoral artery. While turning the client, the nurse discovers blood underneath the client's lower back. The nurse should suspect - bleeding from the incisional site A nurse is completing the admission assessment of a client who will undergo peripheral bypass graft surgery on the left leg. Which of the following is an expected finding? - Report of intermittent claudication in the affected leg A nurse is admitting a client who has a suspected myocardial infarction (MI) and a history of angina. Which of the following findings will help the nurse distinguish angina from an MI? - Angina can be relieved with rest and nitroglycerin
A nurse on a cardiac unit is reviewing the laboratory findings of a client who has a diagnosis of myocardial infarction (MI) and reports that his dyspnea began 2 weeks ago. Which of the following cardiac enzymes would confirm the infarction occurred 14 days ago? - Troponin T A nurse is caring for a client in a clinic who asks the nurse why her provider prescribed 1 aspirin per day. Which of the following is an appropriate response by the nurse? - "Aspirin reduces the formation of blood clots that could cause a heart attack" A nurse is instructing a client who has angina about a new prescription for metoprolol tartrate. Which of the following statements by the client indicates understanding of the teaching? - "I will call my doctor if my pulse rate is less than 60." A nurse is presenting a community education program on recommended lifestyle changes to prevent angina and myocardial infarction. Which of the following changes should the nurse recommend be made first? - Smoking cessation A nurse is caring for a client who has heart failure and reports increased shortness of breath. The nurse increases the oxygen per protocol. Which of the following actions should the nurse take first? - Assist the client into high-Fowler's position A nurse is caring for a client who has heart failure and asks how to limit fluid intake to 2,000 mL/day. Which of the following is an appropriate response by the nurse? - "Pour the amount of fluid you drink into an empty 2 liter bottle to keep track of how much you drink." A nurse is teaching a client who has heart failure about the need to limit sodium in the diet to 2,000 mg daily. Which of the following foods should be consumed in limited quantities? - Cheddar cheese, 2 oz. Hot dog Canned tuna, 3 oz. Baked ham, 3 oz. A nurse is completing discharge teaching to a client who has heart failure and is encouraged to increase potassium in his diet. Which of the following statements by the client indicates understanding of the teaching? - "I will eat more baked potatoes."
Which of the following clients has the greatest risk of acquiring rheumatic endocarditis? - A child who has an upper respiratory streptococcal infection A nurse in a clinic is caring for a client who has been on long-term NSAID therapy to treat myocarditis. Which of the following laboratory findings should be reported to the provider? - Platelets 100,000/mm A nurse is assessing a client who has splinter hemorrhages in her nail beds and reports a fever. For which of the following conditions is the client at risk? - Infective endocarditis A nurse is admitting a client who has suspected rheumatic endocarditis. The nurse should anticipate a prescription from the provider for which of the following laboratory tests to assist in confirmation of this diagnosis? - Throat culture A nurse is performing a physical assessment of a client who has chronic peripheral arterial disease (PAD). Which of the following is an expected finding? - Pallor on elevation of the client's limbs and rubor when his limbs are dependent A nurse is caring for a client who has severe peripheral arterial disease (PAD). The nurse should expect that the client will sleep most comfortably in which of the following positions? - With the affected limb hanging from the bed A nurse is teaching a client who has a new prescription for clopidogrel. Which of the following should be included in the teaching? - Effects may not be apparent for several weeks Monitor for the presence of black, tarry stools A nurse is caring for a client who has a deep-vein thrombosis (DVT) and has been taking unfractionated heparin for 1 week. Two days ago, the provider also prescribed warfarin. The client questions the nurse about receiving both heparin and warfarin at the same time. Which of the following is an appropriate response by the nurse? - "It takes three or four days before the effects of warfarin are achieved and the heparin can be discontinued." A nurse is caring for a client who has chronic venous insufficiency. The provider prescribed thigh-high compression stockings. The nurse should instruct the client to - apply the stockings in the morning upon awakening and before getting out of bed
A nurse is screening a client for hypertension. Which of the following actions by the client increase his risk for hypertension? - Eating popcorn at the movie theater Consuming 36 oz. of beer daily A nurse is caring for a client who is admitted to the emergency department with a blood pressure of 266/147 mm Hg. The client reports a headache and states that she is seeing double. The client states that she ran out of her diltiazem 3 days ago, and she has not been able to purchase more. Which of the following nurse interventions should the nurse expect to perform first? - Obtain IV access and prepare to administer an IV antihypertensive A nurse is providing discharge teaching for a client who has a prescription for furosemide 40 mg PO daily. What time of day should the nurse encourage the client to take this medication? - Morning A nurse is caring for a client who has a new diagnosis of hypertension and a new prescription for spironolactone 25 mg/day. Which of the following statements by the client indicates a need for further teaching? - "I should eat a lot of fruits and vegetables, especially bananas and potatoes." A nurse in an urgent care clinic is obtaining a history from a client who has type 2 diabetes mellitus and a recent diagnosis of hypertension. This is the second time in two weeks that the client experienced hypoglycemia. Which of the following data should the nurse report to the provider? - Takes metoprolol daily A nurse is caring for a client and reviewing a new prescription for an afterload-reducing medication. The nurse should recognize that this medication is administered for which of the following types of shock? - Cardiogenic A nurse is planning care for a client who has septic shock. Which of the following is the priority action for the nurse to take? - Administering antibiotic therapy A nurse in the emergency department is caring for a client who has an allergic reaction to a bee sting. The client is experiencing wheezing and swelling of the tongue. Which of the following medications should the nurse expect to administer first? - Epinephrine
A nurse caring for a client who has hemophilia. The nurse should anticipate a prescription from the provider for which of the following tests? - aPTT A nurse is providing teaching for a client who is to have a bone marrow biopsy of the iliac crest. Which of the following statements made by the client indicates a need for further teaching? - "The type of antibiotic I need to take can be determined by this test." A nurse should remain with a client during the first 15 min of a blood transfusion to - assess for an adverse reaction. A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse take when there is a transfusion reaction? - Stop the transfusion Send the blood bag and IV tubing to the blood bank Maintain an IV infusion with 0.9% sodium chloride A nurse is monitoring a client who began receiving a unit of blood 10 min ago. Which of the following should pose an immediate concern for the nurse? - Dyspnea Client report of itching Client appears flushed A nurse is completing preoperative teaching with a client who will undergo an elective surgical procedure that will include a blood transfusion. Which of the following statements by the nurse should be included in the teaching? - "You will receive the blood you donated 4 weeks prior to the surgery." A nurse is observing a newly hired nurse on the unit who is preparing to administer a blood transfusion. Which of the following actions by the newly hired nurse requires intervention by the nurse? - Verifies blood compatibility and expiration date of the blood with an assistive personnel (AP) A nurse is planning care for a client who has a Hgb of 7.5 and a Hct of 21.5. Which of the following should the nurse include in the plan of care? - Provide assistance with ambulation Monitor oxygen saturation Obtain stool specimen for occult blood
Schedule daily rest periods A nurse is teaching a client who has a new prescription for ferrous sulfate. Which of the following should be included in the teaching? - Food high in vitamin C will promote absorption A nurse is providing discharge teaching to a client who had a gastrectomy for stomach cancer. Which of the following information should be included in the teaching? - "You will need a monthly injection of vitamin B12 for the rest of your life." "Using the nasal spray form of vitamin B12 on a daily basis may be an option." A nurse is completing an integumentary assessment of a client who has anemia. Which of the following is an expected finding? - Spoon-shaped nails A nurse in a clinic receives a phone call from a client seeking information about his new prescription for erythropoietin. Which of the following information should be reviewed with the client? - The client should have his hemoglobin checked twice a week. A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following indicates that the client's clotting factors are becoming depleted? - Platelets 100,000/mm Fibrinogen levels 97 mg/dL A nurse is assessing a client and suspects the client is experiencing disseminated intravascular coagulation (DIC). Which of the following physical findings should the nurse anticipate? - Epistaxis A nurse is caring for a client who has idiopathic thrombocytopenic purpura (ITP). The nurse should notify the provider and report possible small-vessel clotting when which of the following is assessed? - Cyanotic nail beds A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following medications should the nurse anticipate administering to the client? - Heparin A nurse is admitting a client who reports nausea, vomiting, and weakness. Upon assessment, the client has dry oral mucous membranes, temperature 38.5C (101.3F), pulse 92/min, respirations 24/min, skin
A nurse is assessing a client for Chovstek's sign. Which of the following techniques should the nurse use to perform this test? - Tap lightly on the client's cheek A nurse is assessing a client who has hyperkalemia. Which of the following conditions is associated with this electrolyte imbalance? - Diabetic keloacidosis A nurse is caring for a client admitted with confusion and lethargy. The client was found at home unresponsive with an empty bottle of aspirin lying next to her bed. Vital signs reveal a blood pressure of 104/72 mm Hg, heart rate of 116 beats/min with a regular rhythm, and a respiratory rate of 42/min and deep. Which of the following arterial blood gases findings should the nurse expect? - pH 6.98, PaO2 100 mm Hg, PaCO2 30 mm Hg, HCO3- 18 mEq/L A nurse is caring for a client who was in a motor-vehicle accident. He is reporting chest pain and difficulty breathing. A chest x-ray reveals the client has a pneumothorax, and arterial blood gases are obtained. Which of the following findings should the nurse expect? - pH 7.06, PaO2 86 mm Hg, PaCO 52 mm Hg, HCO3- 24 mEq/L A nurse is admitting a client who has been vomiting for 24 hr. Arterial blood gases are obtained. Based on the laboratory findings, which of the following conditions should the nurse expect? - Metabolic alkalosis A nurse is orienting a newly licensed nurse on conditions related to metabolic acidosis. Which of the following statements by the new nurse indicates the teaching has been effective? - "Metabolic acidosis can occur due to diabetic ketoacidosis." A nurse is assessing a client who has pancreatitis. His arterial blood gases reveal metabolic acidosis. Which of the following is an expected finding? - Tachycardia Dysrhythmia Tachypnea A nurse is reviewing the bowel prep using polyethylene glycol with a client scheduled for a colonoscopy. Which of the following should be included in the teaching? - Check with the provider about taking current medications when consuming bowel prep.
A nurse is having difficulty arousing a client following an esophagogastroduodenoscopy (EGD). Which of the following is the priority action by the nurse? - Assess the client's airway A nurse in a clinic is instructing a client about a fecal occult blood test, which requires mailing three specimens. Which of the following statements by the client indicates understanding of the teaching? - "This is an easy way to rule out having colon cancer." A nurse is completing preprocedure teaching for a client who will undergo a sigmoidoscopy. Which of the following should be included in the teaching? - Increased flatulence can occur following the procedure NPO status should be maintained preprocedure A nurse is reviewing the health record of a client who is being admitted with a suspected tumor of the jejunum. The nurse should anticipate a prescription for which of the following test? - Gastrointestinal x- ray with contrast A nurse is caring for a client who had a paracentesis. Which of the following findings indicate the bowel was perforated during the procedure? - Temperature elevation A nurse is providing care to a client who is 1 day postoperative paracentesis. The nurse observes clear, pale-yellow fluid leaking from the operative site. Which of the following is an appropriate nursing intervention? - Apply a dry, sterile dressing A nurse is planning care for a client who has a new prescription for total parenteral nutrition (TPN). Which of the following interventions should be included in the plan of care? - Obtain a capillary blood glucose four times daily. Monitor vital signs three times during the 12-hr shift Change the TPN IV tubing every 24 hr A nurse is completing discharge teaching with a client who is 3 days postoperative for a transverse colostomy. Which of the following should be included in the teaching? - Stoma should be moist and pink
A nurse is teaching a client who has a duodenal ulcer and a new prescription for esomeprazole. Which of the following should be included in the teaching? - Take the medication 1 hr before a meal. Limit NSAIDs when taking this medication. A nurse is completing discharge teaching for a client who has an infection due to Helicobacter pylori (H.pylori). Which of the following statements by the client indicates understanding of the teaching? - "I will take a combination of medications for treatment." A nurse is completing an assessment of a client who has a gastric ulcer. Which of the following are expected findings? - Client reports a sensation of bloating. Client states that pain occurs 1/2 to 1 hr after a meal. Client experiences pain upon palpation of the epigastric region. A nurse is teaching a client who has a new diagnosis of pernicious anemia due to chronic gastritis. Which of the following should be included in the teaching? - A monthly injection of medication is required. A nurse is providing discharge teaching to a client who has a new prescription for aluminum hydroxide. The nurse should advise the client to - wait 1 to 2 hr before taking other oral medications A nurse is planning care for a client who has acute gastritis. Which of the following nursing interventions should the nurse include in the plan of care? - Evaluate intake and output. Monitor laboratory reports of electrolytes. Observe stool characteristics. A nurse is caring for a client who has chronic gastritis and is scheduled for a selective vagotomy. The purpose of this procedure is to - reduce gastric acid secretion. A nurse is completing teaching to a client who has a new prescriptions for famotidine. Which of the following statements by the client indicates understanding of the teaching? - "I will take my pill at meal time."
