ATI - MED SURG EXAM 1 - California State University, Long Beach TTT 67777

ATI - MED SURG EXAM 1

TTT 67777

1.           A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?

a.           Bradycardia

b.           Flushed skin

c.           Frothy sputum – pg.198

d.           Jugular vein distention

2.           A nurse is assessing a client who is experiencing renal colic from a calculus in left renal pelvis. Identify the area where the nurse should expect the client to have referred pain. (Find “hot spots” in the artwork) - CORRECT

3.           A nurse is caring for a client who is receiving peritoneal dialysis and notes a decrease in the dialysate flow rate. Which of the following actions should the nurse take? (Select all the apply.)

a.           Monitor the access site for drainage.

b.           Strip the catheter tubing

c.           Measure the amount of the dialysate outflow

d.           Raise the client to high fowlers position - pg.370: encourage client to lie Supine with head slightly elevated during CCPD and APD treatment.

e.           Position the client to her other side.

4.           A nurse is providing discharge teaching to a client who has an impaired immune system due to chemotherapy. Which of the following information should the nurse include in the teaching?

1. 1. Wash you’r perineal area two times each day with antimicrobial soap.
   2. Change your pet’s litter box daily.
   3. Change the water in your drinking glass every 4 hrs.
   4. Wash your toothbrush in the dishwasher once each month.  

5.           A nurse is planning to insert an indwelling catheter for a female client. Which of the following actions should the nurse plan to take?

a.           Collect urine specimen from the drainage bag 1 hr after insertion

b.           Raise the head of the bed to 45 degrees prior to insertion

c.           Secure the catheter to the client's inner thigh

d.           Attach the bag to the rail of the bed

6.           A nurse is providing teaching for a client who has age-related macular degeneration. Which of the following information should the nurse include in the teaching?

a.           A possible cause of this problem is long-term lack of dietary protein.

b.           You probably have a Detachment of your retina.

c.           You probably have noticed a decline in your central vision. – pg.63

d.           The doctor can perform surgery to correct the start paying the folds in your retina.

7.           A nurse is assessing a client who has cirrhosis. Which of the following findings is the priority for the nurse to report? – Expected Findings: fatigue, Wt loss, abdo.pain, abdo.distention, pruritus.

a.           Platelets 70,000/mm^{3   -} pg.357

b.           Distended abdomen

c.           Alkaline phosphatase 125 units/L

d.           Clay colored stools

8.           A nurse is preparing to discontinue long-term total parenteral nutrition (TPN) therapy for a client for a client. The nurse should plan to discontinue the TPN gradually to reduce the risk of which of the following adverse effects?

a.           Hyperglycemia – if unavailable, do not attempt to catch up by increasing the infusion rate because client can develop Hyperglycemia.

b.           Diarrhea

c.           Constipation

d.           Hypoglycemia – pg.298 – sudden abruption of infusing rate can cause hypoglycemia.

9.           A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse plan to take? - CORRECT

a.           Administer the unit of packed RBC’s over 1 hr.

b.           Obtain the client’s first set of vital signs 1 hr after initiating the transfusion.

c.           Initiate venous access with a 21-gauge needle.

d.           Use Y tubing with 0.9% sodium chloride when administering the transfusion.

10.        A nurse is caring for a female who has toxic shock syndrome.  Which of the following findings should the nurse expect?

1. 1. Elevated platelet count
   2. Generalized rash

■      Whole body rash

1. 1. Decreased total bilirubin
   2. Hypertension

■      Hypotension

11.        A nurse is providing discharge teaching to an older adult client who had an exacerbation of COPD. The client is to start fluticasone by metered-dose inhaler. Which of the following instructions should the nurse include?

a.           Use fluticasone as needed for shortness of breath.

b.           Limit fluid intake to 1 L per day.

c.           Obtain a yearly influenza immunization.

d.           Assist use of pursed-lip breathing.

12.        A nurse is providing discharge teaching to an older adult client following a left total hip arthroplasty. Which of the following instructions should the nurse include in the teaching?

a.           “You can cross your legs at the ankles when sitting down.”

b.           “Clean the incision daily with hydrogen peroxide.”

c.           “Install a raised toilet seat in your bathroom.”

d.           “You should use an incentive spirometer every 8 hrs.”

13.        Missing

14.        A nurse is caring for a client who is postoperative following a femur fracture. Which of the following findings should the nurse report to the provider immediately?

a.           The client reports shortness of breath – sign of surgical complication

b.           The client has a temperature of 38.1 C (100.5F)

c.           The client’s incision is red and warm

d.           The client reports incision pain

15.        A nurse is planning care for a client who Clostridium difficile gastroenteritis. Which of the following is an appropriate nursing action?

a.           Place the client in a protective environment

b.           Obtain a stool specimen with gloves

c.           Clean surfaces with chlorhexidine-bleach

d.           Wash hands with alcohol-based hand rub.

16.        A nurse is setting up a sterile field before performing a dressing change on client who is postoperative. Which of the following actions should the nurse plan to take to maintain the sterile field? (Select all the apply.)

a.           Grasp 2.5 cm (1 in) of the outer edge to open the surgical wrap

b.           Select a work surface at the nurse’s waist level

c.           Apply sterile gloves before opening the pack

d.           Open the first flap of the sterile package toward the nurse's body

e.           Place a surgical pack with a sterile drape on the work surface.

17.        A nurse is caring for a client who has acute appendicitis. Which of the findings is the priority to the provider?

a.           Nausea

b.           Flank pain

c.           Fever

d.           Rigid abdomen

18.        A nurse is caring for a client who is receiving radiation. The client reports nauseas since the therapy was initiated. Which of the following considerations should the nurse include when planning the client’s meals?

a.           Offer frequent, high-carbohydrate meals

b.           Offer highly seasoned foods

c.           Offer a snack prior to radiation therapy

d.           Offer hot beverages with meals

19.        A nurse is caring for a client who is receiving mechanical ventilation. Which of the following interventions should the nurse implement?

a.           Empty water from the ventilator tubing daily.

b.           Suction the client’s airway every 4 hr.

c.           Maintain the client in supine position.

d.           Perform oral care every 2 hr.

20.        A nurse in an emergency department is assessing a client who has cirrhosis of the liver. Which of the following is a priority finding?

a.           Palmar erythema

b.           Spider angiomas

c.           Yellow Sclera

d.           Mental Confusion

21.        A nurse is preparing to administer bumetanide to a client who has heart failure. Which of the following assessment findings should indicate effectiveness of the medication?

a.           Bowel sounds present in 4 quadrants on auscultation

b.           Alert and oriented to time place and person

c.           Lung sounds clear

d.           Apical pulse 80/min and regular

22.        A nurse is caring for a client who has active tuberculosis.  Which of the following interventions should the nurse include in the plan of care?

a.           Perform chest percussion twice daily

b.           Wear a high-efficiency particulate air mask

c.           Initiate droplet precautions

d.           Obtain daily sputum specimen

23.        A nurse is caring for a client who has hypertension and has a new prescription for lisinopril. The nurse should consult with the provider about which of the following medication in the client's medication administration record?

a.           Potassium chloride

b.           Levothyroxine

c.           Acetaminophen

d.           Metformin

24.        A nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan or care?

a.           Avoid use of anticoagulants

b.           Place pillow under client knees

c.           Discourage leg exercises while in bed

d.           Apply compression stocking in lower extremities

25.        What interferes with warfarin therapy?

a.           Potatoes

b.           Oranges

c.           Bananas

d.           Cauliflower

26.        A nurse is administering furosemide 80 to a client with pulmonary edema. Which of the following assessment findings indicates the nurse that the medication is effective?

a.           Elevation in BP

b.           Adventitious breath sounds

c.           Weight loss of 1.8 kg (4lb) in the past 24 hr

d.           Respiratory rate of 24/min

27.        A nurse is caring for a client who has Cushing’s disease. Which of the following findings should the nurse expect?

a.           Weight loss

b.           Hyponatremia

c.           Hyperglycemia

d.           Hypercalcemia

28.        A nurse is monitoring a client who has receiving 2 units packed RBCs. Which of the following manifestations indicates a hemolytic transfusion reaction? (MS RM 10.0 Ch.40

a.           Back pain

b.           Bradycardia

■      tachy

c.           Hypertension

■      Hypotension

d.           Chills

29.        A PACU nurse is monitoring the drainage from a client’s NG tube following abdominal surgery. Which of the following findings in the first postoperative hour should the nurse report to the provider?

a.           75 mL of greenish yellow drainage

b.           100 mL of red drainage

c.           200 mL of brown drainage – purulent

d.           150 mL of serosanguineous drainage

30.        A nurse is performing an admission assessment on a client who has severe chronic kidney disease. Which of the following findings should the nurse expect?

a.           Lethargy – pg.382

b.           Potassium 4.0 mEq/L

c.           Hypotension

d.           Serum creatinine 0.9 mg/dL

31.        A nurse is teaching a client who has hypothyroidism. Which of the following information should the nurse include in the teaching? (Select all the apply.)

a.           You will take medication for this condition for several months

b.           You will need to eat a high-fiber diet to prevent complications of this condition

c.           You might notice that you perspire more with this condition

d.           We will perform laboratory tests to monitor the effect of your medication

e.           This condition can cause you to gain weight.

32.        A nurse is caring for a client who is receiving mechanical ventilation when the low-pressure alarm sounds on the ventilator. Which of the following actions should the nurse take?

a.           Empty water from the client’s ventilator tubing

b.           Evaluate the client for a cuff leak

c.           Suction the client’s airway

d.           Increase the client’s ventilator flow rate

33.        A nurse is reviewing laboratory results for four client who are scheduled for surgery. Which of the following laboratory values should the nurse report to the surgeon?

a.           INR of 1.6

b.           Platelets 95,000/mm³

c.           Hct 42%

d.           WBC 8,000/mm³

34.        A nurse is assessing a client who is receiving valsartan to treat heart failure. Which of the following findings should the nurse identify as an indication that the medication is effective?

a.           Increased potassium level

b.           Decreased blood pressure

c.           Increased heart rate

d.           Decreased urinary output

35.        A nurse is providing teaching to a client following a liver biopsy 1 hour ago. Which of the following positions should the nurse instruct the client to maintain after the procedure?

a.           Prone

b.           Supine

c.           Right lateral

d.           Left lateral