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ATI RN ADULT MEDICAL-SURGICAL
NURSING /RN ADULT MEDICAL
SURGICAL NURSING ACTUAL EXAM
TEST BANK 150 QUESTIONS AND
CORRECT DETAILED ANSWERS,,.
A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the following instructions should the nurse include? - correct answer Flex the foot every hour when awake. Rationale: The nurse should instruct the client to flex the foot every hour to reduce the risk for thromboembolism and promote venous return. A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the following findings is an indication of lung re-expansion? - correct answer Bubbling in the water seal chamber has ceased. Rationale: Bubbling in the water seal chamber ceases when the lung re-expands. A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation. Which of the following values should the nurse identify as a desired outcome for this therapy? - correct answer INR 2. Rationale: Clients receive warfarin therapy to decrease the risk of stroke, myocardial infarction (MI), or pulmonary emboli (PE) from blood clots. Since warfarin is an anticoagulant, the medication must be monitored to ensure the anticoagulation is within the therapeutic range and prevent hemorrhage (high levels of anticoagulation) or stroke, MI, or PE (low levels of anticoagulation). An INR of 2.5 is within the targeted therapeutic range of 2 to 3 for a client who has atrial fibrillation. A home health nurse is providing teaching to a client who has a stage 1 pressure injury on the greater trochanter of his left hip. Which of the following instructions should the nurse include in the teaching? - correct answer Change position every hour Rationale: Changing position every 1 to 2 hr decreases pressure on bony prominences. The nurse should also instruct the client to limit the angle of the hips when in a lateral position to no more than 30°. This positioning prevents direct pressure on the trochanter.
A nurse is assessing a client following the completion of hemodialysis. Which of the following findings is the nurse's priority to report to the provider? - correct answer Restlessness Rationale: Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding to report to the provider is restlessness, which can be an indication the client is experiencing disequilibrium syndrome. Disequilibrium syndrome is caused by the rapid removal of electrolytes from the client's blood and can lead to dysrhythmias or seizures. Other manifestations include nausea, vomiting, fatigue, and headache. A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The client is unable to void on the bedpan. Which of the following actions should the nurse take first? - correct answer Scan the bladder with a portable ultrasound. Rationale: The first action the nurse should take using the nursing process is to assess the client. Scanning the bladder with a portable ultrasound device will determine the amount of urine in the bladder A nurse is planning a health promotional presentation for a group of African American clients at a community center. Which of the following disorders presents the greatest risk to this group of clients? - correct answer Hypertension Rationale: When using the safety/risk reduction approach to client care, the nurse should determine that the disorder with the greatest risk for this group of clients is hypertension. The prevalence of hypertension is highest among African American clients, followed by Caucasian clients, and then Hispanic clients. A nurse is caring for a client who has DKA. Which of the following findings should indicate to the nurse that the client's condition is improving? - correct answer Glucose 272 mg/dL Rationale: A glucose reading less than 300 mg/dL indicates improvement in the client's status. A nurse is caring for a client following extubation of an endotracheal tube 10 min. ago. Which of the following findings should the nurse report to the provider immediately? - correct answer Stridor Rationale: Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is stridor. Stridor can indicate a narrowing airway or possible obstruction caused by edema or laryngeal spasms. The nurse should report the finding immediately and implement an intervention. A nurse is caring for a client who had a nephrostomy tube inserted 112 hr ago. Which of the following findings should the nurse report to the provider? - correct answer The client reports back pain
A nurse is providing education to a client who is at risk for osteoporosis. Which of the following instructions should the nurse include? - correct answer Walk for 30 min four times per week. Rationale: Weight-bearing exercises promote bone mass. Therefore, walking can help the client prevent osteoporosis. A nurse is providing teaching to a client who is perimenopausal and has a prescription for hormone replacement therapy. For which of the following? - correct answer Calf pain Numbness in the arm Intense headache Rationale: Calf pain is correct. Calf pain is an indication of deep-vein thrombosis. The client should report this finding to the provider immediately. Numbness in the arms is correct. Numbness in the arms can indicate a cerebrovascular accident, which is an adverse effect of hormone replacement therapy. The client should report this finding to the provider immediately. Intense headache is correct. An intense headache can indicate a cerebrovascular accident, which is an adverse effect of hormone replacement therapy. The client should report this finding to the provider immediately. A nurse is evaluating the plan of care for four clients after 2 days of hospitalization. The nurse should identify the need to revise the plan for which of the following clients? - correct answer A client who is postoperative following abdominal surgery and reports feeling that something "popped" when they coughed Rationale: A feeling of something popping or loosening with coughing might indicate a wound dehiscence. This client will need to have revisions to the plan of care, which can include management of the dehiscence, prevention of evisceration, or possible surgical repair of an evisceration if one occurs. A nurse is caring for a client who has hypothyroidism. Which of the following manifestations should the nurse expect? - correct answer Constipation Rationale: A client who has hypothyroidism can experience constipation due to the decrease in the client's metabolism, resulting in slow motility of the gastrointestinal tract. The nurse should instruct the client to increase fiber and fluid intake to reduce the risk for constipation. A nurse is caring for a client who has cervical spinal cord injury sustained 1 month ago. Which of the following manifestations indicates that the client is experiencing autonomic dysreflexia (AD)? - correct answer Heart Rate 52/min
Rationale: A client who is experiencing AD will exhibit multiple manifestations, including bradycardia, severe headache, and flushing. A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse take? - correct answer Place a pressure bag around the flush solutions Rationale: The nurse should place a pressure bag around the flush solution of 0.9% sodium chloride because the pressure from an artery is greater than that of the line. A nurse is reviewing the medical record of a client who has osteomyelitis and a prescription for gentamicin. Which of the following findings from the client's medical record should indicate to the nurse the need to withhold the medication and notify the provider? - correct answer Serum creatinine Rationale: A client who has an elevated serum creatinine level should not receive gentamicin because the medication is nephrotoxic. A nurse is preparing to administer phenytoin 600 mg PO daily to a client. he amount available is oral solution 125 mg/5 mL. How many mL should the nurse administer? - correct answer 24 Rationale: Desired/have x mL A nurse is providing preoperative teaching for a client who is scheduled for a mastectomy. Which of the following statements should the nurse make? - correct answer "I will refer you to community resources that can provide support." Rationale: The nurse should provide the client with support resources, including community programs, to assist the client with acceptance of body image changes. A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following interventions should the nurse include in the plan? - correct answer Encourage the client to take deep breaths after the procedure. Rationale: After a thoracentesis, the client should deep breathe to re-expand the lung. A nurse is providing discharge instructions to a client who has laryngeal cancer and is receiving radiation therapy. Which of the following statements by the client indicates an understanding of the teaching? - correct answer "I will avoid direct exposure to the sun." Rationale: The client should avoid exposure of irradiated skin areas to the sun for at least 1 year after completing radiation therapy. Skin in the radiation path is especially sensitive to sun damage.
A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which f the following findings should the nurse identify as a manifestation of this condition? - correct answer Pain that increases with passive movement Rationale: The nurse should identify that a client who has compartment syndrome experiences pain that increases with passive movement. Compartment syndrome results from a decrease in blood flow in the extremity caused by a decrease in the muscle compartment size due to a cast that is too tight. A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and notes clots in the client's indwelling urinary catheter and a decrease in urinary output. Which of the following actions should the nurse take? - correct answer Irrigate the indwelling urinary catheter. Rationale: The nurse should irrigate the client's catheter per facility protocol to remove clots obstructing the urine flow. A nurse is assessing a client while suctioning the client's tracheostomy tube. Which of the following findings should indicate to the nurse the client is experiencing hypoxia? - correct answer The client's heart rate increases. Rationale: Hypoxia related to suctioning can cause the client's heart rate to increase. If this occurs, the nurse should discontinue the suctioning and manually oxygenate the client with 100% oxygen. The nurse should instruct the client to take three or four deep breaths prior to suctioning to reduce the risk for hypoxia. A nurse is providing discharge teaching to a client who is postoperative following a modified radical mastectomy. Which of the following instructions should the nurse include? - correct answer Numbness can occur along the inside of the affected arm. Rationale: The nurse should instruct the client that numbness can occur near the incision and along the inside of the affected arm due to nerve injury. A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr ago. The nurse should identify which of the following findings as an indication of a myocardial infarction (MI)? - correct answer Troponin I 8 ng/mL Rationale: Troponins are proteins present in skeletal and cardiac muscle that are involved with muscle contraction. The elevation of either troponin T or troponin I is an indication of cardiac injury. The client's laboratory value is above the expected reference range for troponin I, indicating an MI has occurred.
A nurse is planning discharge teaching for a client who has an external fixation device for a fracture of the lower extremity. Which of the following instructions should the nurse include in the plan of care? - correct answer Use crutches with rubber tips. Rationale: Using crutches with rubber tips prevents the client from slipping and decreases the risk of falls. A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of the following findings should the nurse identify as the priority? - correct answer Report of a sore throat Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a report of a sore throat, which could be a manifestation of an infection. The client is at risk for neutropenia due to myelosuppression; therefore, an infection could lead to sepsis. A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron supplement. Which of the following statements by the client indicates an understanding of the teaching? - correct answer "I will eat more high-fiber foods" Rationale: The client should eat high-fiber foods to help prevent constipation, which is a common adverse effect of oral iron supplements. A nurse is administering packed RBCs to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction? - correct answer Low back pain and apprehension Rationale: Hemolytic transfusion reactions result from the infusion of incompatible blood products and create a systemic inflammatory response. Manifestations include low back pain, hypotension, tachycardia, and apprehension. A nurse is providing discharge teaching to a client who is to self-administer heparin subcutaneously. Which of the following statements by the client indicates an understanding of the teaching? - correct answer "I will use an electric razor to shave." Rationale: Heparin is an anticoagulant that places the client at the risk for bleeding. Therefore, the nurse should instruct the client to use an electric razor when shaving to reduce the risk of cuts to the skin. A nurse is teaching a client about osteoporosis prevention. The nurse should instruct the client that which of the following medications can increase their risk for developing osteoporosis? - correct answer Prednisone
A nurse is teaching a client about the use of transcutaneous electrical nerve stimulation (TENS for the management of bone cancer pain. The nurse should explain that applying a TENS unit to the painful area has which of the following effects? - correct answer A tingling sensation replacing the pain Rationale: A TENS unit applies small electric currents to the painful area, with the client increasing the current until the "pins and needles" sensation overrides the pain. A nurse is caring for a client who has homonymous hemianopsia as result of a stroke. To reduce the risk of falls when ambulating the nurse should provide which of the following instructions to the client? - correct answer "Scan the environment by turning your head from side to side." Rationale: Homonymous hemianopsia is the loss of the same visual field in both eyes. Turning their head from side to side helps enlarge a client's visual field. This technique is also useful for the client during mealtimes. A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the following results should the nurse expect? - correct answer PaCO2 56mmHg Rationale: A client who has COPD retains PaCO2 due to the weakening and the collapse of the alveolar sacs, which decreases the area in the lungs for gas exchange and causes the PaCO2 to increase above the expected reference range. A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect? - correct answer Hair loss on the lower legs Rationale: The nurse should expect a client who has peripheral arterial disease to have hair loss on the lower legs as a result of impaired arterial circulation affecting follicular growth. A nurse is performing a preoperative assessment for a client. The nurse should identify that an allergy to which of the following foods can indicate a latex allergy? - correct answer Avocados Rationale: Clients who have an avocado allergy might have an allergic reaction or a sensitivity to latex. Allergies to certain fruits, such as strawberries and bananas, can also indicate latex allergy or sensitivity. A nurse is planning care for a client who is postoperative following laparotomy and has a closed-suction drain. which of the following actions should the nurse take to manage the drain? - correct answer Compress the drain reservoir after emptying. Rationale: Compressing the reservoir creates a vacuum that draws fluid out of the wound, through the drain, and into the reservoir.
A nurse is caring for a client who has terminal cancer. The client tells the nurse, "I wish I could stop these treatments. I am ready to die." Which of the following statements should the nurse make? - correct answer "Discontinuing with the treatments is your choice if it is your wish to do so." Rationale: The nurse should recognize the client's right to refuse the treatments and inform the client of this right. The nurse should advocate for the client and offer to contact the provider for the client. A nurse is caring for an older adult client who has dementia and requires acute care for a respiratory infection. The client is agitated and is attempting to remove their IV catheter. Which of the following actions should nurse take to avoid restraining the client? - correct answer Keep the client occupied with a manual activity. Rationale: The nurse should provide the client with a manual activity such as a puzzle or an art project. This can help to distract the client from the IV catheter. A nurse is caring for a client who has breast cancer and tells the nurse that they would like to have acupuncture because it provides greater relief than pain medication. Which of the following statements should the nurse make? - correct answer "I can speak with the provider about incorporating acupuncture into your treatment plan." Rationale: The nurse should serve as an advocate for the client by acting on behalf of the client and offering to speak with the provider. The client has the right to make choices and decisions about their treatment and the nurse should support these decisions and assist the client to carry them out. A nurse is obtaining a medication history from a client who is scheduled to undergo cataract surgery. The nurse should recognize that which of the following client medications is a contraindication for the surgery and notify the provider? - correct answer Warfarin Rationale: Warfarin is an anticoagulant, which increases the client's risk for bleeding, and is contraindicated for a client scheduled for eye or central nervous system surgery. A nurse is reviewing the laboratory results of a client who has aplastic anemia. Which of the following findings indicates a potential complication? - correct answer WBC count 2,000/mm Rationale: A WBC count of 2,000/mm3 is below the expected reference range and indicates a risk for severe immunosuppression. A nurse in an emergency department is assessing an older adult client who has a fractured wrist following a fall. During the assessment, the client states, "Last week I crashed my car because my vision
A nurse is assessing a client who has advanced lung cancer and is receiving palliative care. The client has just undergone thoracentesis. The nurse should expect a reduction in which of the following common manifestations of advanced cancer? - correct answer Dyspnea Rationale: Thoracentesis, the removal of pleural fluid, can temporarily relieve hypoxia and thus ease the client's breathing and improve comfort. A nurse is planning care for a client who is postoperative following a parathyroidectomy. Which of the following actions should the nurse identify as the priority? - correct answer Place a tracheostomy tray at the bedside. Rationale: The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to place a tracheostomy tray at the client's bedside in case of airway obstruction. A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After ensuring a patent airway, which of the following nursing interventions is the priority? - correct answer Applying oxygen via face mask Rationale: Evidence-based practice indicates that the priority intervention is for the nurse to apply oxygen. The nurse should use a high-flow nonrebreather mask to deliver oxygen at 90% to 100%. A nurse is reviewing the medical record of a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect? - correct answer Facial butterfly rash Rationale: A butterfly rash is a manifestation of SLE. It appears as a dry, red rash on the client's cheeks and nose and can disappear during times of remission. A nurse on a medical-surgical unit is reviewing the medical record of an older adult client who is receiving IV fluid therapy. Which of the following client information should indicate to the nurse that the client requires re-evaluation of the IV therapy prescription? - correct answer BUN Rationale: The client's Hct and BUN levels indicate dehydration and require an increase in the IV fluid infusion rate. A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following should the nurse plan to administer? - correct answer Regular insulin 20 units IV bolus Rationale: DKA is a complication of diabetes mellitus that results in dehydration, ketosis, metabolic acidosis, and elevated blood glucose levels. Management of DKA involves providing hydration,
correcting acid-base imbalances, and decreasing blood glucose levels. Regular insulin is a fast-acting insulin that can be effective within 10 min when administered intravenously. A nurse is reviewing the laboratory results of a client who has AIDS and is taking amphotericin B for a fungal infection. The nurse should identify that which of the following values is an indication of an adverse effect of the medication? - correct answer BUN 34 mg/dL Rationale: Amphotericin B is nephrotoxic. Therefore, an elevated BUN or creatinine level can indicate renal impairment. The nurse should notify the provider of this result. A nurse is providing teaching to a client who has asthma about the use of a metered-dose inhaler. The nurse should identify that which of the following client actions indicates an understanding of the teaching? - correct answer Holding breath for 10 seconds after inhaling Rationale: The client should hold their breath for 10 seconds after inhaling so the medication can move deep into the airways. A nurse is assessing a client who is at risk for the development of pernicious anemia from peptic ulcer disease. Which of the following images depicts a condition caused by pernicious anemia? - correct answer Glossitis Rationale: This image depicts glossitis, which can indicate pernicious anemia. Glossitis, a smooth red tongue, is also a manifestation of deficiencies in vitamin B6, zinc, niacin, or folic acid. A nurse is receiving report on a client who is postoperative following an open repair of Zenker's diverticulum. The nurse should anticipate the surgical incision to be in which of the following locations? - correct answer Near the patient's throat Rationale: Zenker's diverticulum, or pharyngeal pouch, is a herniation of the esophagus occurring through the cricopharyngeal muscle in the midline of the neck. Repair of the diverticulum is accomplished through an open incision in the client's neck. A nurse is providing discharge instructions to a client who has active TB. Which of the following information should the nurse include in the instructions? - correct answer Sputum specimens are necessary ever 2 to 4 weeks until there are three negative cultures. Rationale: After three negative sputum cultures, the client is no longer considered infectious
Rationale: Using the airway, breathing, circulation approach to client care, the first action the nurse should take is to administer oxygen. The nurse should then initiate IV therapy to support circulation by expanding the client's intravascular fluid volume. Next, the nurse should insert an NG tube to monitor the rate of bleeding and prevent gastric dilatation. Finally, to prevent a stress ulcer, the nurse can administer famotidine when the client is no longer bleeding. A nurse is providing teaching to a client who has AIDS. Which of the following statements by the client indicates an understanding of the teaching? - correct answer "I will take my temperature once a day." Rationale: A client who has AIDS is immunocompromised and is at risk for infection. The client should check their temperature daily to identify a temperature greater than 37.8° C (100° F), which is an early manifestation of an infection. A nurse is caring for a client who is having a tonic-clonic seizure while in bed and has become cyanotic. Which of the following actions should the nurse take? (Select all that apply.) - correct answer Prepare to suction the client's airway Loosen restrictive clothing on the client Rationale: Prepare to suction the client's airway is correct. The client's airway can become obstructed and the nurse may need to suction to clear the client's airway after the seizure. Loosen restrictive clothing on the client is correct. The nurse should loosen restrictive clothing so the client is able to move freely during the seizure. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) and is NPO. When reviewing the chart, the nurse notes the following prescription: capillary blood glucose AC and HS. Which of the following actions should the nurse take? - correct answer Contact the provider to clarify the prescription. Rationale: Mealtimes do not pertain to this client due to the NPO status. The nurse should monitor the client's glucose levels on a set schedule, either every 6 hr or per facility protocol. Thus, the prescription requires clarification. A nurse is checking the ECG rhythm strip for a client who has a temporary pacemaker. The nurse notes a pacemaker artifact followed by a QRS complex. Which of the following actions should the nurse take? - correct answer Document that depolarization has occurred. Rationale: When a pacing stimulus is delivered to the ventricle, a pacemaker artifact appears as a spike on the ECG rhythm strip. The spike should be followed by a QRS complex, which indicates pacemaker capture or depolarization.
A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Which of the following statements made by the client reflects an understanding of the teaching? - correct answer "My joints ache because I have Lyme disease." Rationale: Lyme disease is a vector-borne illness transmitted by the deer tick. The disease course occurs in three stages beginning with joint and muscle pain in stage I. If left untreated, these symptoms continue throughout stage II and, by stage III, become chronic. Other chronic complications include memory problems and fatigue. A nurse is providing teaching to a client who has a recent diagnosis of constipation-predominant irritable bowel syndrome. Which of the following instruction should the nurse include in the teaching? - correct answer Consume at least 30 g of fiber daily. Rationale: Irritable bowel syndrome is a gastrointestinal disorder characterized by abdominal pain, bloating, and either constipation or diarrhea or a mixture of both. Consuming a diet high in dietary fiber helps produce bulky, soft stools and establish regular bowel patterns. A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The client's initial vital signs were heart rate 80/min, blood pressure 130/70 mm Hg, respiratory rate 16/min, and temperature 36 C (98.7 F). Which of the following vital sign changes should alert the nurse that the client might be hemorrhaging? - correct answer Heart rate 110/min Rationale: One of the first signs of hemorrhage is an increase in the heart rate from the client's baseline, which occurs to compensate for blood loss. A nurse is caring for a client who has a positive culture for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take? - correct answer Bathe the client using chlorhexidine solution. Rationale: The nurse should bathe the client using chlorhexidine solution because it reduces the risk of transmission of MRSA to other areas of the body. A nurse is caring for a client who has increased intracranial pressure (ICP) and is receiving mannitol via continuous IV infusion. Which of the following findings should the nurse report to the provider as an adverse effect of this medication? - correct answer Crackles heard on auscultation Rationale: Mannitol is an osmotic diuretic that prevents the reabsorption of water in the kidneys, thus increasing urinary output. With the exception of the brain, mannitol can leave the vascular system at the capillary site, which can result in edema. The nurse should identify crackles as a manifestations of pulmonary edema and notify the provider. Other manifestations include dyspnea and decreased oxygen saturation.
