ATI RN MED SURG 2019 PROCTORED EXAM

S/S of pneumothorax ● Signs of respiratory distress (tachypnea, tachycardia, hypoxia, cyanosis, dyspnea, and use of accessory muscles) ● Tracheal deviation to the UNAFFECTED side (tension pneumothorax) ● REDUCED or ABSENT breath sounds on the affected side 39. A nurse is caring for a client who is 2 days postoperative following below the knee amputation and asks about the purpose of maintaining an elastic bandage around residual limb of the extremity. Which of the following is an appropriate response by the nurse? a. The elastic bandage will prevent a postoperative wound infection b. The elastic bandage will prevent excessive edema – pg.442 c. The elastic bandage will keep you from seeing the surgical site d. The elastic bandage will keep the sutures from loosening 40. A nurse is assessing a client who has malnutrition. Which of the following findings should the nurse expect? a. Hyperproteinemia b. Cachexia c. Diplopia d. Hypermagnesemia muscle wasting syndrome is loss of weight, muscle atrophy, fatigue, weakness, and significant loss of appetite in someone who is not actively trying to lose weight 41. A nurse is caring for a client who is receiving chemotherapy and requests information about acupuncture to relieve some of the side effects. Which of the following findings should the nurse identify as a contraindication to receiving this alternative therapy? a. Lymphedema b. Urticaria c. Mouth sores d. Headaches 42. 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 take a laxative when I am constipated b. I will expect my stools to be loose – pg.533 c. I will eat a higher-fiber diet d. I will empty my bag when it is full 43. A nurse is providing instructions about foot care for a client who has peripheral disease. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching? a. I soak my feet in hot water before trimming my toenails b. I rest in my recliner with my feet elevated for about an hour every afternoon c. I use my heating pad on low setting to keep my feet warm. d. I apply a lubricating lotion to the cracked area on the soles of my feet – NOT CORRECT 44. A nurse is planning care for a client who has a pulmonary embolism and a prescription for enoxaparin via subcutaneous injection. Which of the following interventions should the nurse include? a. Assess the client’s tools for occult blood b. Massage the injection site c. Instruct the client to limit vitamin K intake d. Monitor the client's PT levels 45. A nurse is caring for a client who is receiving total parenteral nutrition through 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. Discontinue the infusion and flush the line. b. Decrease the rate of the infusion to last until the new bag is available. c. Switch the infusion to a 10% dextrose solution. d. Start an infusion of 0.45% sodium chloride solution.