ATI Med-Surg Ch. 26-50, All Questions with accurate answers, Graded A. Latest Update.

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ATI Med-Surg Ch. 26-50, All Questions with accurate answers, Graded A. Latest Update. A nurse in the emergency department is assessing a client who was in a motor vehicle crash. Findings includ... e absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, hear rate 124/min, respiratory rate 38/min, temperature 38.6C (101/4F), and SaO2 92% on room air. Which of the following actions should the nurse take first? - ✔?Administer oxygen via a high-flow mask A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome. Which of the following statements by the newly licensed nurse indicates understanding of the teaching? - ✔?"This medication is given to facilitate ventilation." A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome (ARDS)? - ✔?A client who experienced a near-drowning incident A client following coronary artery bypass graft surgery A client who has dysphagia A client who experienced a drug overdose A nurse is planning care for a client who has severe acute respiratory distress syndrome (SARS). Which of the following should be included in the plan of care for this client? - ✔?Providing supplemental oxygen Administration of bronchodilators Maintaining ventilatory support A nurse is caring for a client who is receiving vecuronium for acute respiratory distress syndrome (ARDS). Which of the following medications should the nurse anticipate administering with this medication? - ✔?Fentanyl Midazolam A nurse is orienting a newly licensed nurse on the care of a client who is receiving hemodynamic monitoring. Which of the following statements by the newly licensed nurse indicates the teaching was effective? - ✔?"A chest x-ray is needed to verify placement." A nurse is caring for a client following a coronary artery bypass graft (CABG). Hemodynamic monitoring has been initiated. Which of the following actions by the nurse facilitate correct monitoring readings? - ✔?Level transducer to phlebostatic axis Zero transducer to room air Observe trends in readings Compare readings to physical assessment A nurse is caring for a client who is receiving hemodynamic monitoring and has the following hemodynamic readings: PAS 34 mm Hg, PAD 21 mm Hg, PAWP 16 mm Hg, and CVP 12 mm Hg. For which of the following is the client at risk? - ✔?Heart failure Cor pulmonale Pulmonary hypertension Peripheral edema A nurse is teaching a client the importance of remaining still following angiography. Which of the following is an appropriate statement by the nurse? - ✔?"Too much activity places you at risk for bleeding." A nurse is reviewing a new prescription to administer 0.9% sodium chloride IV at 50 mL/hr to a client who is receiving hemodynamic monitoring and has an indwelling IV catheter in the left hand. Which of the following sites can be used for administering this solution? - ✔?Peripheral saline lock Port on proximal (CVP) lumen of pulmonary artery (PA) catheter A nurse on a cardiac unit is caring for a group of clients. The nurse should recognize which of the following clients as being at risk for the development of a dysrhythmia? - ✔?A client who has metabolic alkalosis A client who has COPD A client who underwent stent placement in a coronary artery A nurse working on a cardiac unit is admitting a client who is to undergo a cardioversion and is reviewing the health record. Which of the following data requires that the nurse notify the provider to cancel the procedure? Mar: Ferrous Sulfate 200 mg PO 0800 and 2000, Diazepam 2 mg PO 0800 and 2000, Isosorbide 2.5 mg PO 4x a day AC and HS Vital Signs: 0800 T 99F (37.2C), BP 142/86 mm Hg, HR 88/min and irregular, Respirations 20/min History and Physical: bariatric surgery 10 years ago, dyspnea with exertion for 3 yrs., Atrial fibrillation began 3 yr. ago, Client reports taking the following medications for the past 6 weeks-iron supplement, multivitamin, antilipemic, and nitroglycerin - ✔?Medication history A nurse is caring for a client who experienced defibrillation. Which of the following should be included in the documentation of this procedure? - ✔?Follow-up ECG Energy settings used Skin condition under electrodes A nurse on a cardiac unit is caring for a client who is on telemetry. The nurse recognizes the client's heart rate is 46/min and notifies the provider. The nurse should anticipate that which of the following management strategies will be be used for this client? - ✔?Pacemaker insertion A student nurse is observing a cardioversion procedure and hears the team leader call out, "Stand clear." The student should recognize the purpose of this action is to alert personnel that - ✔?they cannot be in contact with equipment connected to the client A nurse is admitting a client to the coronary care unit following placement of a temporary pacemaker. Which of the following nursing actions should the nurse use to promote client safety? - ✔?Wear gloves when handling pacemaker leads Verify the use of three-pronged grounding plugs Minimize client's should movements A nurse is admitting a client who has complete heart block as demonstrated by ECG. The client's pulse rate is 34/min, blood pressure is 83/48 mm Hg, and he is lethargic and unable to complete sentences. Which of the following actions should the nurse perform first? - ✔?Cleanse the client's skin with soap and water A nurse is caring for a client following the insertion of a temporary venous pacemaker via the femoral artery that is set as a VVI pacemaker rate of 70/min. Which of the following findings should the nurse report to the provider? - ✔?Cool and clammy foot with capillary refill of 5 seconds Twitching of intercostal muscle A nurse is completing discharge teaching with a client who has a permanent pacemaker. Which of the following statements by the client indicates a need for further teaching? - ✔?"I will have to disconnect my garage door opener." A cardiac nurse educator is reviewing the use of the fixed rate mode pacemaker with a group of newly hired nurses. Which of the following statements by a newly hired nurse indicates understanding of the review? - ✔?"This means the pacemaker fires in an asynchronous pattern." A nurse is caring for a client who is 4 hr postoperative following coronary artery bypass grafting (CABG) surgery. He is able to inspire 200 mL with the incentive spirometer, then refuses to cough because he is tired and it hurts too much. Which of the following is an appropriate nursing intervention? - ✔?Administer IV bolus analgesic, and return in 15 min. A nurse is caring for a client following peripheral bypass graft surgery of the left lower extremity. Which of the following client findings pose an immediate concern? - ✔?Capillary refill of affected limb of 6 seconds Mottled appearance of the limb A nurse educator is reviewing the use of cardiopulmonary bypass during surgery for coronary artery bypass grafting with a croup of nurses. Which of the following should be included in the discussion? - ✔?The client's demand for oxygen is lowered Motion of the heart ceases Rewarming of the client takes place A nurse is caring for a client following an angioplasty that was inserted through the femoral artery. While turning the client, the nurse discovers blood underneath the client's lower back. The nurse should suspect - ✔?bleeding from the incisional site A nurse is completing the admission assessment of a client who will undergo peripheral bypass graft surgery on the left leg. Which of the following is an expected finding? - ✔?Report of intermittent claudication in the affected leg A nurse is admitting a client who has a suspected myocardial infarction (MI) and a history of angina. Which of the following findings will help the nurse distinguish angina from an MI? - ✔?Angina can be relieved with rest and nitroglycerin A nurse on a cardiac unit is reviewing the laboratory findings of a client who has a diagnosis of myocardial infarction (MI) and reports that his dyspnea began 2 weeks ago. Which of the following cardiac enzymes would confirm the infarction occurred 14 days ago? - ✔?Troponin T A nurse is caring for a client in a clinic who asks the nurse why her provider prescribed 1 aspirin per day. Which of the following is an appropriate response by the nurse? - ✔?"Aspirin reduces the formation of blood clots that could cause a heart attack" A nurse is instructing a client who has angina about a new prescription for metoprolol tartrate. Which of the following statements by the client indicates understanding of the teaching? - ✔?"I will call my doctor if my pulse rate is less than 60." A nurse is presenting a community education program on recommended lifestyle changes to prevent angina and myocardial infarction. Which of the following changes should the nurse recommend be made first? - ✔?Smoking cessation A nurse is caring for a client who has heart failure and reports increased shortness of breath. The nurse increases the oxygen per protocol. Which of the following actions should the nurse take first? - ✔?Assist the client into high-Fowler's position A nurse is caring for a client who has heart failure and asks how to limit fluid intake to 2,000 mL/day. Which of the following is an appropriate response by the nurse? - ✔?"Pour the amount of fluid you drink into an empty 2 liter bottle to keep track of how much you drink." A nurse is teaching a client who has heart failure about the need to limit sodium in the diet to 2,000 mg daily. Which of the following foods should be consumed in limited quantities? - ✔?Cheddar cheese, 2 oz. Hot dog Canned tuna, 3 oz. Baked ham, 3 oz. A nurse is completing discharge teaching to a client who has heart failure and is encouraged to increase potassium in his diet. Which of the following statements by the client indicates understanding of the teaching? - ✔?"I will eat more baked potatoes." A nurse is completing the admission assessment of a client who has suspected pulmonary edema. Which of the following are expected findings? - ✔?Tachypnea Persistent cough Orthopnea A nurse is completing discharge teaching with a client who had a surgical placement of a mechanical heart valve. Which of the following statements by the client indicates understanding of the teaching? - ✔?"I will have my prothrombin time checked on a regular basis." A nurse is completing the admission physical assessment of a client who has a history of mitral valve insufficiency. Which of the following is an expected finding? - ✔?Crackles in lung bases A nurse is reviewing the health record of a client who is being evaluated for possible valvular heart disease. The nurse should recognize which of the following data as risk factors for this condition? - ✔?Surgical repair of an atrial septal defect at age 2 Hypertension for 5 years Diastolic murmur present A nurse is caring for a 72-year-old client who is to undergo a percutaneous balloon vavuloplasty. The client's daughter asks the nurse to explain the expected outcome of this procedure. Which of the following is an appropriate response by the nurse? - ✔?"This will permit your mother to resume her activities of daily living." A nurse educator is reviewing expected findings in a client who has right-sided valvular heart disease with a group of nurses. Which of the following should be included in the discussion? - ✔?Dyspnea Client report of fatigue Peripheral edema A nurse is caring for a client who has pericarditis. Which of the following expected findings should the nurse anticipate? - ✔?Friction Rub Which of the following clients has the greatest risk of acquiring rheumatic endocarditis? - ✔?A child who has an upper respiratory streptococcal infection A nurse in a clinic is caring for a client who has been on long-term NSAID therapy to treat myocarditis. Which of the following laboratory findings should be reported to the provider? - ✔?Platelets 100,000/mm3 A nurse is assessing a client who has splinter hemorrhages in her nail beds and reports a fever. For which of the following conditions is the client at risk? - ✔?Infective endocarditis A nurse is admitting a client who has suspected rheumatic endocarditis. The nurse should anticipate a prescription from the provider for which of the following laboratory tests to assist in confirmation of this diagnosis? - ✔?Throat culture A nurse is performing a physical assessment of a client who has chronic peripheral arterial disease (PAD). Which of the following is an expected finding? - ✔?Pallor on elevation of the client's limbs and rubor when his limbs are dependent A nurse is caring for a client who has severe peripheral arterial disease (PAD). The nurse should expect that the client will sleep most comfortably in which of the following positions? - ✔?With the affected limb hanging from the bed A nurse is teaching a client who has a new prescription for clopidogrel. Which of the following should be included in the teaching? - ✔?Effects may not be apparent for several weeks Monitor for the presence of black, tarry stools A nurse is caring for a client who has a deep-vein thrombosis (DVT) and has been taking unfractionated heparin for 1 week. Two days ago, the provider also prescribed warfarin. The client questions the nurse about receiving both heparin and warfarin at the same time. Which of the following is an appropriate response by the nurse? - ✔?"It takes three or four days before the effects of warfarin are achieved and the heparin can be discontinued." A nurse is caring for a client who has chronic venous insufficiency. The provider prescribed thigh-high compression stockings. The nurse should instruct the client to - ✔?apply the stockings in the morning upon awakening and before getting out of bed [Show More]

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