ATI RN Med Surg 2 latest update with Answers and rationale.

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A nurse is caring for a client who has chronic venous insufficiency and a prescription for thigh high compression stockings. Which action should the nurse take? a. Elevate legs for 10 min, 2-3 times a... day while wearing stockings b. apply the stockings in the morning upon awakening and before getting out of bed c. roll the stockings down to the knees to relieve discomfort on the legs d. remove the stockings while out of bed for 1 hour, 4 times a day, to allow the legs to rest B. Applying the stockings in the morning upon waking up before getting out of bed reduces venous stasis and assists in the venous return of blood to the heart. A nurse is assessing a client who has PAD. Which of the following should the nurse expect? a. edema around ankles and feet b. ulceration around the medial malleoli c. scaling edema of the lower legs with stasis dermatitis d. pallor on elevation of the limbs, and rubber when the limbs are dependent D. In a client who has PAD, pallor is seen in the extremities when the limbs are elevated, and rubor occurs when they are lowered A nurse is teaching a client who has a new diagnosis of severe peripheral arterial disease. Which should the nurse include? a. Wear tightly fitting insulated socks with shoes when going outside b. elevate both legs above heart when resting c. apply a heating pad to both legs for comfort d. place both legs in dependent position while sleeping D. Such as hanging off of the bed. This can alleviate swelling and discomfort of the legs A nurse is teaching a client who has a new prescription for clopidogrel. Select all that the nurse should include. a. avoid consumption of grapefruit b. monitor black and tarry stools c. take this when you have pain d. schedule weekly PT test e. Limit food sources containing vit. K while taking this A, B A nurse is caring for a client who has a DVT and has been taking heparin for a week. Two days ago, the provider also prescribed warfarin. The client asks the nurse about receiving both at the same time. What should the nurse say? a. I will remind your provider that you are already receiving heparin b. your lab findings indicate that 2 anticoagulants are needed c. it takes 3-4 days for the therapeutic effects of warfarin, and then heparin can be discontinued d. only one of these medications are being given to treat your DVT C. warfarin depresses synthesis of clotting factors but does not have an effect on clotting factors that are present. It takes 3-4 days for the clotting factors that are present to decay and for the therapeutic effects of warfarin to occur. A nurse in an outpatient clinic is assessing a client who reports night sweats and fatigue. He states he had a cough along with nausea and diarrhea. His temperature is 38.1 C orally. The client is afraid he has HIV. Which action should the nurse take? Select all that apply. a. perform a physical assessment b. determine when s/s began c. teach the client about HIV transmission d. draw blood for HIV testing e. obtain a sexual history a, b, e a nurse is caring for a client who is suspected of having HIV. The nurse should identify that which of the following DX tests and lab values are used to confirm HIV infection? Select all that apply. a. western blot b. Indirect immunofluorescence assay c. CD4+ T-lymphocyte count d. HIV RNA quantification test e. CSF analysis a, b a nurse is providing teaching for a client who has stage 3 HIV disease. Which of the following statements by the client should indicate to the nurse an understanding of the teaching? a. I will wear gloves while changing the kitty litter b. I will rinse raw fruits with water before eating them c. I will wear a mask when around family members who are ill d. I will cook vegetables before eating them D, no raw fruits/veggies A nurse is assessing a client for HIV. Which are risk factors? Select all that apply. a. perinatal exposure b. pregnancy c. monogamous sex partner d. older woman adult e. occupational exposure A, D, E [Show More]

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