ATI MED-SURG PART B TEST BANK WITH ANSWER KEY

79. A nurse is reinforcing teaching with a client about testicular self-examination. Which of the following instructions should the nurse include in the teaching? a) "Perform testicular self-examination after taking a warm shower." The nurse should instruct the client to perform testicular self-examination after taking a warm shower or bath. This causes relaxation of the scrotal skin, which allows for better palpation of the testes.) b) "Examine both testicles at the same time." (The nurse should instruct the client to examine each testicle individually to feel for any lumps or abnormalities.) c) "Use the palm of your hand to palpate for abnormalities." (The nurse should instruct the client to use the thumbs and fingers of both hands when palpating each testicle.) d) "Perform testicular self-examination every 6 months." (The nurse should instruct the client to perform testicular self-examination monthly on approximately the same day of each month) 80. A nurse is caring for a client who is in Buck’s traction for a fractured hip. The client reports increased pain at the sited of the fracture. Which of the following actions should the nurse take? a) Massage the area. (The nurse should avoid massaging the areas, because it might increase the client's pain. The nurse should monitor the bony prominences of a client in traction to detect findings of tissue breakdown or impaired circulation.) b) Remove the weights. (The nurse should not remove the weights unless there is a prescription to do so) c) Loosen the ropes. (The nurse should not loosen the ropes because this can affect the weight applied to the traction.) d) Reposition the client. (When the client's body is out of alignment with the traction, muscle spasms develop, causing increased pain. Therefore, the nurse should reposition the client, ensuring there is a straight line from the client's hip to the traction rope and pulley, evaluate the client's response, and provide other interventions as needed.) 81. A nurse in a clinic is collecting data from a client who has hyperthyroidism and has been taking methimazole for 4 weeks. Which of the following statements by the client indicates a therapeutic response of the medication? a) "I have been sleeping less since I started the medication." (The nurse should expect the client to report improved sleeping patterns after 4 weeks of methimazole therapy.) b) "I have gained 3 pounds since my last appointment." (Hyperthyroidism can cause weight loss. Therefore, the nurse should identify weight gain as an indication that the methimazole therapy has been effective.) c) "My bowel movements have become more frequent." (The nurse should expect the client to report regular bowel movements and absence of diarrhea after 4 weeks of methimazole therapy.) d) "I urinate more often than before." (The nurse should expect the client to report urinating less frequently after 4 weeks of methimazole therapy.) 82. A nurse is collecting data from a client who has 30% body surface area partial-thickness and full-thickness burns. Which of the following findings indicates that fluid resuscitation is adequate? a) Granulation tissue is present. (The nurse should monitor the client's wounds because infection is a complication of burns. The presence of granulation tissue is an indicator used to monitor the effectiveness of wound therapy.) b) Urine output is 50 mL/hr. (The nurse should closely monitor the client's urinary output as an indicator of effective fluid resuscitation. A urinary output greater than 30 to 50 mL/hr indicates that fluid resuscitation is adequate.) c) Lung sounds are clear. (The nurse should monitor the client's lung sounds because pneumonia is a complication of burns. Clear lung sounds only indicate that the client has not had excessive fluid replacement, not whether fluid resuscitation was adequate.) d) Oxygen saturation level is 95%. (The nurse should monitor the client's oxygen saturation level because respiratory problems are a complication of burns. An oxygen saturation within the expected reference range indicates adequate perfusion of oxygen to the tissues.) 83. A nurse is reinforcing teaching with a client prior to removal of a leg cast. Which of the following statements should indicate to the nurse that the client understands the teaching? a) "I will scrub the skin to remove the old skin flakes." (Scrubbing the skin can damage its deeper layers. The client should use a gentle technique, such as soaking the skin or applying moisturizing lotion, to remove dry, scaly flakes.) b) "I can expect to my leg to be swollen after the cast is removed." (The nurse should instruct the client that the leg might appear atrophied following cast removal due to disuse of the muscles.) c) "I can go back to my usual activities as soon as the cast is off." (The client should resume activities gradually to avoid placing unnecessary stress on the healing bone.) d) "I will feel vibrations on my leg from the cast cutter."(The client will feel heat and vibrations from the cast cutter on the affected extremity. The nurse should assure the client that cast removal should not cause any pain.) 84. A nurse is contributing to the plan of care for a client who has pericarditis. In which of the following positions should the nurse plan to place the client to decrease plan? a) Semi-Fowler's (The nurse should place a client in Semi-Fowler's position to facilitate breathing as part of management of peritonitis.) b) Supine with lower extremities elevated (The nurse should place a client who is in shock in the supine position with lower extremities elevated or modified Trendelenburg position, to increase the venous return to the heart.) c) Upright, leaning forward (The nurse should plan to place a client who has pericarditis in an upright position, leaning forward, to facilitate breathing and decrease pain.) d) Side-lying with knees bent (The nurse should place a client in side-lying position with knees bent to assist in decreasing the pain related to a unilateral or sensory motor deficit on one side of the body.) 85. A nurse is caring for a client who is receiving a continuous tube feeding of 60 mL/hr at 1.2 cal/mL. How many calories will the client receive in 12 hr? (Round the answer to the nearest whole number. Use a leading zero if applicable. Do not use a trailing zero.) Follow these steps to calculate the calorie intake: Step 1: What is the unit of measurement the nurse should calculate? calories Step 2: What is the volume the nurse should infuse? 60 mL/hr x 12 hr = 720 mL Step 3: What is the total infusion time? 12 hr Step 4: Should the nurse convert the units of measurement? No Step 5: Set up an equation and solve for X. 720 mL x 1.2 cal/mL = calories X = 864 cal Step 6: Round if necessary. Step 7: Reassess to determine if the amount to administer makes sense. If the provider prescribed 60 mL to infuse over 12 hr, it makes sense to administer 720 mL/12 hr. If there are 1.2 cal/mL, it makes sense that the total number of calories the nurse will deliver in 12 hr is 864. 86. A nurse is reinforcing teaching about nutrition choices with a client who has leukemia and is receiving chemotherapy. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching? a) "I drink bottled water." (To avoid exposure to bacteria, clients who have cancer and are receiving chemotherapy should be sure that drinking water is safe. Drinking fresh, bottled water limits exposure to bacteria.) b) "I eat at a salad bar for lunch." (Clients who have cancer and are receiving chemotherapy are at risk for leukopenia. The nurse should recommend the client avoid salad bars and buffets because of the risk of exposure to bacteria.) c) "I like to eat steak cooked medium." (Clients who have cancer and are receiving chemotherapy should cook foods that can contain bacteria, such as meat, to the well-done stage to prevent infection.) d) "I put plenty of pepper on my soft-boiled eggs." (Clients who have cancer and are receiving chemotherapy should avoid undercooked eggs and pepper because of the risk of exposure to bacteria.)