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ATI RN Adult Medical Surgical Practice 2024
-2025 with NGN
A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurse's priority? Anorexia Abdominal pain radiating to the right shoulder Tachycardia Rebound abdominal tenderness Tachycardia -Tachycardia is a manifestation of biliary colic, which can lead to shock. The nurse should position the head of the client's bed flat and report this finding immediately A nurse is caring for a client who is undergoing hemodialysis to treat end-stage kidney disease (ESKD). The client reports muscle cramps and tingling sensation in their hands. Which of the following medications should the nurse plan to administer? Epoetin alfa Furosemide Captopril Calcium carbonate Calcium carbonate A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching? "I will monitor my blood pressure while taking this medication" "I should take a vitamin D supplement to increase the effectiveness of the medication." "I should inform the provider if I experience an increased appetite while taking this medication" "I will decrease the amount of protein in my diet while taking this medication." "I will monitor my blood pressure while taking this medication"
-monitor their blood pressure while taking this medication because hypertension is a common adverse effect and can lead to hypertensive encephalopathy. Rationale -client requires an adequate intake of iron, folic acid, and vitamin B12 while taking this medication because they are essential to the production of erythrocytes. -increase the amount of protein in their diet while receiving chemotherapy to decrease the risk for infection. The nurse is caring for a group of clients. The nurse should plan to make a referral to physical therapy for which of the following clients? -A client who is receiving preoperative teaching for a right knee arthroplasty. -A client who states they will have difficulty obtaining a walker for home use. -A client who reports an increase in pain following a left hip arthroplasty. -A client who is having emotional difficulty accepting that they have a prosthetic leg. A client who is receiving preoperative teaching for a right knee arthroplasty. -should make a referral to physical therapy for a client who is receiving preoperative teaching for a knee arthroplasty so the client can begin understanding postoperative exercises and physical restrictions. -should make a referral to a social worker for walker -should contact the provider for a client who is experiencing increased pain following a left hip arthroplasty. -should refer the client to a counselor to assist with coping with the adjustment to the need of a prosthetic leg. A nurse is providing teaching to a female client who has a history of urinary tract infections (UTIs). Which of the following information should the nurse include in the teaching? Avoid foods that are high in ascorbic acid. Add oatmeal to the water when taking a tub bath. Urinate every 6 hr. Take daily cranberry supplements. Take daily cranberry supplements -.take cranberry supplements or drink low-fructose cranberry juice because it contains compounds that adhere to the urinary tract wall, decreasing the risk for developing a UTI
Aged cheese Peppermint candy Enriched pasta Aged cheese A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. Which of the following prescribed medications should the nurse instruct the client to withhold for 48 hr prior to cardioversion? Enoxaparin Metformin Diazepam Digoxin Digoxin A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a productive cough. Which of the following actions should the nurse take first? Obtain a sputum sample. Administer antipyretics. Provide hand hygiene education. Initiate airborne precautions. Initiate airborne precautions. -exhibiting manifestations of tuberculosis. The greatest risk in this client situation is for other people in the facility to acquire an airborne disease from this client. Therefore, the first action the nurse should take is to initiate airborne precautions. A nurse is caring for a client who has a stage 111 pressure injury. Which of the following findings contributes to delayed wound healing? WBC count 6,000/mm BMI 24 Urine output 25 mL/hr Albumin 4 g/dL
Urine output 25 mL/hr -Urinary output reflects fluid status. Inadequate urine output can indicate dehydration, which can delay wound healing. Rationale -well-managed pain level enhances a client’s willingness to increase mobility. -BMI less than 18.5 are considered at risk for complications, such as poor wound healing. (24 is within normal limits) A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first? -Obtain ABGs -Administer Propofol to the client. -Instruct the client to allow the machine to breathe for them. -Disconnect the machine and manually ventilate the client. Instruct the client to allow the machine to breathe for them. -should first use the least restrictive intervention. Therefore, the first action the nurse should take is to provide verbal instructions and emotional support to help the client relax and allow the ventilator to work. A nurse is caring for a client who has hepatic encephalopathy that is being treated withy lactulose. The client is experiencing excessive stools. Which of the following findings is an adverse effect of this medication? Hypokalemia Hypercalcemia Gastrointestinal bleeding Confusion Hypokalemia A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit? Heart rate 110/min Blood pressure 138/90 mm Hg Urine specific gravity 1. BUN 15 mg/dL
Acute chest syndrome is correct. which can be caused by respiratory infections and debris from sickled cells. The client is displaying manifestations of acute chest syndrome, which include cough, shortness of breath, wheezing, tachypnea, fever, and chest pain. Pneumonia is correct. as evidenced by the manifestations of cough, shortness of breath, fever, tachypnea, blood-tinged sputum, and chest pain. A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of the following precautions should the nurse implement? Place a padded tongue blade at the client's bedside. Keep the side rails lowered on the client's bed. Maintain the client's bed at hip level and above. Ensure the client has a patent IV. Ensure the client has a patent IV. -The nurse should ensure the client has IV access in the event that the client requires medication to stop seizure activity. A nurse is ass4ess9ing a client who has had a plaster cast applied to their left leg 2 hr ago. Which of the following actions should the nurse take? Inspect the cast for drainage once every 24 hr Check that one finger fits between the cast and the leg. Perform neurovascular checks every 2 to 3 hr. Make sure the client has a warm blanket covering the cast. Check that one finger fits between the cast and the leg. -make sure the cast is not too tight, the nurse should be able to slide one finger under the cast. It is not uncommon for casts to loosen as swelling subsides, but that should not be an issue 2 hr after application. Rationale -inspect the cast for drainage and alignment at least once every 8 to 12 hr. -For the first 24 hr after cast application, the nurse should check the neurovascular status of the client's leg every hour. -cast is uncovered to allow for thorough air drying of the plaster. Also, the heat that is generated by the drying process has to escape. A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions is the nurse's priority?
Initiate oxygen at 2 L/min via nasal cannula Apply firm pressure to the insertion site Take the client's vital signs. Obtain a stat order for an aPTT Apply firm pressure to the insertion site -greatest risk to the client is bleeding. Therefore, the priority intervention is for the nurse to apply firm pressure to the hematoma to stop the bleeding. A nurse is assessing a male client for an inguinal hernia. Which of the following areas should the nurse palpate to verify that the client has an inguinal hernia? Belly button Upper groin Lower groin Upper groin A nurse is teaching a class about client rights. Which of the following instructions should the nurse include? A client should sign an informed consent before receiving a placebo during a research trial. A client cannot refuse to sign a consent form for a life-saving treatment. A client who has a mental illness is unable to give informed consent. An unemancipated minor needs guardian consent for substance use disorder treatment. A client should sign an informed consent before receiving a placebo during a research trial. -ensure a client has provided informed consent before administering a placebo. Placebos should not be used outside of approved clinical research in which the client has consented to participate. Rationale -unemancipated minor has the right to consent to treatment for substance use disorder. A nurse in a provider's office is caring for a client who requests sildenafil to treat erectile dysfunction. Which of the following statements should the nurse make? "You might need to take a stool softener while taking this medication." "You will not be abled to use sildenafil if you have diabetes." "You will need to limit your caffeine intake if you start taking sildenafil."
Orthostatic hypotension A nurse is assessing a client who had extracorporeal shock wave lithotripsy (ESWL) 6 hr ago. Which of the following findings should the nurse expect? Stone fragments in the urine Fever Deceased urine output Bruising on the lower abdomen Stone fragments in the urine -ESWL is an effort to break the calculi so that the fragments pass down the ureter, into the bladder, and through the urethra during voiding. Following the procedure, the nurse should strain the client's urine to confirm the passage of stones. A nurse is caring for a client who is postoperative following abdominal surgery. 1100: Client received from PACU 1200: Client reports nausea and pain as 8 on a scale of 0 to 10. Abdominal dressing intact, no further drainage noted. Urine output 15 mL since arrival from PACU. Analgesic and antiemetic administered as prescribed. 1230: Client reports relief from nausea and pain as 4 on a scale of 0 to 10. SaO2 96%. Repositioned for comfort. Encouraged to turn, cough, and deep breathe. 1300: No additional urine output since 1200 Which of the following actions should the nurse take? (Select all that apply) Plan to ambulate the client as soon as possible Instruct the client to splint the abdomen with a pillow for coughing Report urinary output to the provider Ask the client to rate their pain on a 0 to 10 scale. Apply oxygen via a face mask. Instruct the client to splint the abdomen with a pillow for coughing is correct. It is important for the client to turn, cough, and deep breathe to reduce the risk for respiratory complications. The nurse should instruct the client to splint the incision while performing these actions to reduce the risk of complications to the surgical incision.
Plan to ambulate the client as soon as possible is correct. The nurse should plan to ambulate the client as soon as possible to promote ventilation and decrease the risk of thrombosis. Report urinary output to the provider is correct. The client should produce at least 30 mL of urine per hour. Therefore, the nurse should report this finding to the provider. Ask the client to rate their pain on a 0 to 10 pain scale is correct. The nurse should have the client rate their pain prior to and following the administration of pain medication to evaluate its effectiveness. A nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. Which of the following statements buy the client indicates and understanding of the teaching? " I should take calcium supplements so the medication will work better in my system" "I am taking this medication to increase my energy level" "This medication can cause my blood pressure to drop" "I will not need to restrict protein in my diet while taking this medication" "I am taking this medication to increase my energy level"
- goal of erythropoietin therapy is to increase the level of hematocrit in clients who have anemia. When the medication is effective, the client should have a decrease in fatigue and an improvement in activity tolerance. Rationale -need adequate iron stores for erythropoietin therapy to be effective. Clients are encouraged to consume foods high in iron such as beef, liver, pork, and veal. -erythropoietin increases RBC production, which can result in hypertension, not hypotension. -Erythropoietin does not affect the client's protein requirements, but the client should continue to restrict protein as prescribed by the provider to manage kidney disease. A nurse is creating a plan of care for a client who has neutropenia as a result of chemotherapy. Which of the following interventions should the nurse include in the plan? Monitor the client's temperature every 4 hr Insert an indwelling urinary catheter for the client. Request the client's bathroom to be cleaned three times each week. Place a box of latex gloves just outside the client's room. Monitor the client's temperature every 4 hr -monitor the temperature of a client who has neutropenia every 4 hr because the client's reduced amount of leukocytes greatly increases the client's risk for infection.
Rationale -Many medications, including aspirin and aminoglycosides, can cause ringing of the ears, but this is not an adverse effect A nurse is providing preoperative teaching for a client who is scheduled for an open cholecystectomy. Which of the following actions should the nurse take? Teach the importance of a clear liquid diet after discharge Tell the client to remove the incisional adhesive strips 3 days after discharge. Demonstrate ways to deep breathe and cough Instruct the client to maintain bed rest for 48 hr Demonstrate ways to deep breathe and cough -demonstrate deep breathing and coughing exercises and explain the importance of splinting the incision to reduce the risk for respiratory complications. Rationale -instruct the client to ambulate as soon as possible to prevent postoperative complications, such as deep-vein thrombosis or pneumonia. -incisional adhesive strips will begin to fall off 7 to 10 days after application and that the provider might remove the adhesive strips during that timeframe. A nurse is caring for a client. 1000: Client is on continuous ambulatory peritoneal dialysis (CAPD) and reports dialysate appeared cloudy this morning. 1300: Client is lying in bed with the knees flexed, guarding the abdomen. Abdomen is slightly distended, hypoactive bowel sounds. Client reports nausea. Reports pain as 6 non a scale of 0 to 10. Provider notified and updated with client condition and diagnostic results. Diagnostic Results WBC count 17,000/mm Abdominal x-ray result: Fluid noted in the abdominal cavity and inflammation noted in the large intestines. The client is experiencing manifestations of (Condition) _____due to (Client finding) _____. Condition: Myxedema coma, dysrhythmias, hemorrhage, pneumonia, or peritonitis Client finding: X-ray results, oxygen saturation, platelet count, thyroid level, potassium level
The client is experiencing manifestations of peritonitis due to X-ray results. A nurse is caring for a client who presents to the clinic for a 1-week follow-up visit after hospitalization for heart failure. Exhibit question Prescriptions Digoxin 0.25 mg PO daily Furosemide 40 mg PO daily Potassium chloride 20 mEq/L PO daily History and physical Discharge: Weight 66.7 kg (147 lb) SaO2 94% 2+ pedal edema Heart rate 74/min Current: Weight 67.1 kg (148 lb) SaO2 92% 1+ pedal edema Heart rate 55/min Based on the information in the client's chart, which of the following findings should the nurse report to the provider? Potassium 4.1 mEq/L Heart rate 55/min SaO2 92% Weight 67.1 kg (148lb) Heart rate 55/min -heart rate of 55/min is a decrease from the client's baseline of 74/min, and it can indicate the development of digoxin toxicity. Rationale -report a client's weight gain of 1.4 kg (3 lb) in a day or 2.3 kg (5 lb) or more in a week. A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place which of the following items at the client's bedside? Suction machine
"I will use my hands rather than a washcloth to clean the radiation area" "I will be able to be out in the sun 1 month after my radiation treatments are over" "I will use a heating pad on my neck if it becomes sore during the radiation therapy" "I will use my hands rather than a washcloth to clean the radiation area" -gently wash the radiation area with their hands using warm water and mild soap to protect the skin from further irritation. Rationale -ink markings designate the exact radiation area. The client should not remove these markings -Radiation therapy causes skin to become sensitive to the effects of sun exposure and increases the risk for developing skin cancer. -avoid exposing the treatment area to heat as this can cause further irritation to the skin. A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following laboratory values should the nurse report to the provider? Potassium 4 mEq/L WBC count 10,000/mm Hct 45% Hgb 8 g/dL Hgb 8 g/dL A nurse is caring for a client. The nurse is reviewing the client's diagnostic results. Skip Nurse's' Notes Diagnostic Results : 1000: Sodium 150 mEq/L (136-145) Potassium 4.8 mEq/L (3.5-5) Calcium 9.5 mg/dL (7.6-10.4) BUN 24 mg/dL (10-20) WBC count 12,000/mm3 (5,000-10,000) ABG's pH 7.35 (7.35-7.45) PCO2 50 mm Hg (35-45) HCO3 24 mEq/L (22-26)
Chest x-ray reveals increased opacity in the bilateral posterior lobes Vital signs: Temperature 38.6C (101.5F) Heart Rate 98/min Respiratory rate 24/min Blood Pressure 110/56 mm Hg Oxygen saturation 88% on room air Which of the following findings requires follow-up by the nurse? (Select all that apply) Calcium level HCO3 level BUN level WBC count Oxygen saturation level PCO2 level Chest X-ray BUN level is correct. The client's BUN is elevated, which is a manifestation of dehydration or kidney disease. WBC count is correct. The client has an elevated WBC count, which indicates an infection. Oxygen saturation level is correct. The client's oxygen saturation is decreased, which is a manifestation of pneumonia. PCO2 level is correct. The client has an elevated PCO2 level, which indicates retention of carbon dioxide. Chest x-ray is correct. The client's chest x-ray indicates increased opacity in the bilateral posterior lobes, which is a manifestation of pneumonia. A nurse is caring for a client. A nurse is reviewing the client's medical record. Review exhibit 1-3 and answer question: Click to highlight the findings below that indicate that the client has a potential problem. Client is short of breath and has a productive cough with yellow mucus "I could barely breathe when I got up this morning and I had a throbbing headache" Capillary refill less than 2 seconds Client is diaphoretic
Client has productive cough with yellow mucous. Could barely breathe when he got up this morning and had a throbbing headache. Client is diaphoretic, crackles heard in posterior lungs. Diagnostic Results: Sodium 150 mEq/L (136-145) BUN 24 mg/dL (10-20) WBC count 12,000/mm3 (5,000-10,000) Chest X-ray reveals increased opacity in the bilateral posterior lobes. VS: Temperature 38.6C (101.5F) Respiratory rate 24/min Oxygen saturation 88% on room air Potential prescription is anticipated, nonessential, or contraindicated. (A N C)
- Cough and deep breathe every 2 hr.
- Perform neurological checks every 2 hr
- Famotidine 40 mg PO daily
- Acetaminophen 500 mg PO every 6 hr as needed 5) Administer oxygen at 3 L/min via nasal cannula
- Limit the client's fluid intake to 1,500 mL per day
- Obtain a sputum Cough and deep breathe every 2 hr is anticipated. The nurse should anticipate a prescription for coughing and deep breathing to promote lung expansion and improve impaired gas exchange.
- Perform neurological checks every 2 hr (N)
- Famotidine 40 mg PO daily (N)
- Acetaminophen 500 mg PO every 6 hr as needed (A)
- Administer oxygen at 3 L/min via nasal cannula ( A)
- Limit the client's fluid intake to 1,500 mL per day (C)
- Obtain a sputum culture and sensitivity. (A) A nurse is caring for a client. Same client. The nurse is reviewing the client's medical record. Day 3: 0800 Supplemental oxygen is use at 2 L/min via nasal cannula. Client reports difficulty coughing up mucus. Encouraged the client to cough and deep breathe. Sodium 146 mEq/L (136-145) - previously 150 Potassium 5.4 mEq/L (3.5-5) - previously 4. BUN 22 mg/dL (10-20) - previously 24
WBC count 15,000/mm3 (5,000-10,000) - previously 12, Sputum culture and sensitivity results indicate streptococcal pneumonia. Temperature 38.6C (101.5F) Respiratory rate 22 Oxygen saturation 97% on 2 L/min Select the 3 findings that require nursing intervention Heart rate Temperature Potassium level WBC count Oxygen saturation Temperature Potassium level WBC count The nurse is caring for a client. Same client. The nurse is reviewing the client's medical record from Day
Click to highlight the findings below that indicate the client is improving. Heart rate 72/min Respiratory rate 20/min Blood pressure 128/ Oxygen saturation 95% on room air Lung sounds are diminished in the bilateral posterior bases with occasional crackles heard upon auscultation Cough is productive with yellow mucus Heart rate 72/min Respiratory rate 20/min Blood pressure 128/ Oxygen saturation 95% on room air A nurse in the ICU is assessing a client who has traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing's triad? Hypotension Tachypnea Nuchal rigidity Bradycardia
