NURS 1234 ATI MED-SURG A (Updated 2020) _ Miami Dade College | NURS1234 ATI MED-SURG A _ A Grade

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NURS 1234 ATI MED-SURG A (Updated 2020) _ Miami Dade College
 Med-Surg Practice A 1. A nurse has just received a report on a client following a transurethral resection of the prostate (TURP) 12 hr... ago. After listening to the report in an audio clip, the nurse should identify which of the following as the priority finding? (Your going to have to click to listen) 2. A nurse is caring for a client who has a disposable chest drainage system with a water seal chamber. The nurse is preparing to measure the drainage at the end of the shift. Locate the place where the nurse should mark and measure the drainage for the shift. (You going to have to select the HOTSPOT on picture) 3. A nurse is monitoring a client receiving general anesthesia. The nurse should recognize which of the following as a clinic al manifestation of malignant hyperthermia? 4. A nurse is caring for a client who is 2 hr post-op following a traditional open approach cholecystectomy. Which of the following indicates the need for further nursing assessment? 5. A nurse is caring for a client who is receiving peritoneal dialysis. The client is reporting anorexia and constipation. Which of the following should the nurse include in the client’s plan of care? 6. A nurse is teaching self-care to a client who has a new colostomy. Which of the following is appropriate information to be included in the teaching? 7. A nurse admits an older client to the emergency department with a fractured left wrist following a fall. During the assessment, the client states, “Last week I crashed my car b/c my vision suddenly became blurry.” Which of the following is the highest priority action by the nurse? 8. A nurse is caring for a client who has chronic renal failure. The provider prescribes (Epogen) injections three times per week. Which of the following statements by the client indicates a need for further teaching about the effects of erythropoietin? 9. A client has been receiving propranolol hydrochloride (Inderal) 40 mg PO daily for hypertension. Which of the following indicates that the client is experiencing an adverse reaction to this medication? 10. A nurse on a medical-surgical unit reviews the medical record of an older adult client who is receiving IV fluid therapy. Which of the following client information should indicate to the nurse that the client requires a revision of his IV therapy prescription? 11. A clinic nurse is reviewing laboratory results of four clients. Which of the following clients demonstrates the desired therapeutic effect of the treatment regimen? 12. A client with atrial fibrillation is prescribed digoxin (Lanoxin). Which of the following statements by the client indicates to the nurse that further teaching is needed? 13. A nurse is caring for a client who is receiving total parenteral nutrition. A new bag is not available when the current infusion is nearly completed. Which of the following actions should the nurse take? 14. A client receiving general anesthesia during major surgery has a sudden elevation in temperature. The provider suspects malignant hyperthermia. The nurse should anticipate a prescription foer which of the following medications? 15. A nurse is teaching a client who has a known allergy to bee venom and has a prescription for epinephrine (EpiPen Auto- Injector) how to respond in the event he is stung by a bee. Identify the sequence the client should follow. 16. A nurse is caring for a client who has pneumonia and has been prescribed incentive spirometry. Which of the following findings indicates the desired outcome of this intervention? 17. A nurse in the emergency department is assessing a client who has a history of hypothyroidism. Which of the following assessment findings should indicate to the nurse that the client is at risk for myxedema coma? 18. A nurse is providing discharge instructions to a client who has active tuberculosis (TB). Which of the following should be included in the discharge instructions? 19. A nurse is preparing to perform a 12-lead ECG on a client. Which of the following actions should the nurse plan to take? 20. A nurse is providing teaching to a client who is at risk for developing type 2 diabetes mellitus. The nurse should inform the client that which of the following clinical manifestations indicate diabetes? 21. A nurse is caring for a client who had a gastrectomy 5 days ago. Which of the following interventions will assist in the prevention of dumping syndrome? 22. A nurse is caring for a client who has had a cerebrovascular accident. Which of the following findings indicates that homonymous hemianopsia is present? 23. A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following findings should indicate to the nurse that the client’s condition is improving? 24. A nurse is checking the rhythm strip for a client who has a temporary pacemaker. The nurse notes a spike (pacemaker artifact) Followed by a QRS complex. Which of the following action should the nurse take? 25. When caring for an older adult client with pain, which of the following should the nurse consider regarding pain management? 26. A nurse is planning to provide preoperative teaching for a client who is scheduled for a laparoscopic cholecystectomy tomorrow. Which of the following instructions is the highest priority? 27. A nurse is caring for a client who has a central venous device. Which of the following should the nurse know before performing a complete assessment of the device? 28. An older adult client is brought to the emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration? 29. A nurse is assigned to care for a client with a spinal cord injury and paraplegia. The client has lost 8lbs in the past 2 weeks & has a low albumin level. Which of the following assessment findings is the highest priority? 30. A nurse is caring for a client who has portal hypertension. The client had vomiting of blood mixed with food after a meal. Which of the following actions should the nurse take first? 31. A nurse is caring for a client receiving mechanical ventilation via tracheostomy tube. The nurse should recognize which of the following as a complication associated with long term mechanical ventilation? 32. A nurse is caring for a client who is to be started on total parenteral nutrition (TPN). The client is to receive 2,000 kcal per day. The TPN solution has 500 kcal/L. The IV pump should be set at how many mL/hr? 33. A nurse is providing teaching to a client who has received a new hearing aid. Which of the following responses by the client indicates understanding? 34. A client taking digoxin (Lanoxin) has a digoxin level of 3.0 ng/mL. For which of the following findings should the nurse monitor? 35. A nurse is caring for a client who is 12hr post-op following a colon resection and has the following vital signs: respirations 20/min, pulse 118/min, & blood pressure 100/60 mm Hg. Which of the following should the nurse anticipate administering first? 36. A client has been prescribed 2 units of packed RBCs. The nurse should recognize which of the following as an appropriate access to use for the transfusion? 37. A nurse is administering packed RBCs to a client. Which of the following assessment findings indicate a hemolytic transfusion reaction? 38. A nurse admits a client with anorexia, low-grade fever, night sweats, & a productive cough. Which of the following should the nurse do first? 39. A nurse notes crackles bilaterally in the lower lobes of the lungs of a client who had a myocardial infarction (MI) 24hr ago. The nurse notifies the provider. Which of the following medications should the nurse anticipate administering? 40. A nurse is providing teaching to a client recently diagnosed with irritable bowel syndrome. Which of the following should the nurse include in the teaching? 41. A nurse in the emergency department is assessing a client who has detachment of the retina. Which of the following should the nurse expect the client to report? 42. A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which of the following findings indicated that the client is experiencing intracranial pressure? 43. A nurse is caring for a client who had an open reduction and internal fixation of a femoral fracture. The client received 5mg of oxycodone/acetaminophen (Percocet) PO 20 min ago for a pain level of 7 on a scale of 0 to 10. The client is now reporting a pain level of 8. Which of the following actions should the nurse take first? 44. A nurse is caring for a client who recently had a cerebrovascular accident that resulted in left-sided hemiplegia & dysarthia. Which of the following is the hightest proiority nursing intervention for this client? 45. A nurse in the emergency department is caring for a client who sustained a left leg fracture and just had a plaster-of-Paris cast applied. While waiting for the provider to write discharge orders, the nurse checks ‘on the client. Which of the following statements indicates a need for action by the nurse? 46. A nurse is caring for a client who has biliary colic. Which of the following treatments should be effective in managing the client’s pain? 47. A nurse us notified by the blood bank that one unit of packed RBCs is ready for administration to a client. Which of the following actions should the nurse take first? 48. A nurse is assessing a client following the application of a short leg cast. Which of the following is the highest priority finding? 49. A nurse is caring for a client who reports abdominal pain. The nurse finds the abdomen is distended and auscultates hypoactive bowel sounds. Which of the following laboratory values should the nurse expect related to these findings? 50. A nurse is providing information to a client receiving an IV infusion of potassium. The nurse should teach the client to report which of the following findings immediately? 51. A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, & has jugular vein distention. Which of the following actions should the nurse anticipate taking? 52. A nurse observes a client in the hallway who is having a generalized tonic-clonic seizure. The client has become cyanotic. Which of the following nursing interventions is appropriate for this client? 53. A home health nurse is assessing a client for signs and symptoms of adverse effects of radiation therapy for laryngeal cancer. Which of the following client reports should cause the nurse the greatest concern? 54. A nurse is caring for a client receiving oxygen therapy for respiratory acidosis related to and exacerbation of asthma. Which of the following ABG values indicated a therapeutic response to the treatment? 55. A nurse is caring for a male client who has heart failure and has a prescription for digoxin (Lanoxin). Which of the following findings indicates that the client is at risk for digoxin toxicity? 56. A nurse is caring for a client who has COPD and is receiving nebulizer treatments of acetycysteine (Mucomyst) every 6hr. Which of the following client statements indicates that the medication is effective? 57. A nurse is reviewing a client’s morning laboratory values. The client’s potassium is 5.8 mEq/L. Which of the following is the highest priority action by the nurse? 58. A nurse is caring for a client who had an open thoractomy with chest tube insertion. Which of the following actions should the nurse take? 59. A nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. The client is experiencing excessive stools. Which of the following should the nurse recognize as an adverse effect of this medication? 60. A nurse is caring for a client with stage I pressure ulcer on the greater trochanter of the left hip. The nurse should instruct the client to? 61. A nurse is assisting a provider with the placement of a nontunneled percutaneous centralized catheter in the client’s subclavian vein. Which of the following actions should the nurse take? 62. A nurse is caring for a client in the PACU following a bronchoscopy. Which of the following assessments findings has the highest priority? 63. A nurse is caring for a client who has diabetes insipidus. Which of the following interventions should the nurse plan to implement? 64. A nurse is caring for a client who is recovering form a thyroidectomy. The client has a large amount of serosangguineous drainage on the neck dressing and is experiencing laryngeal stridor. Which of the following interventions should the nurse take? 65. A nurse is caring for a client who has sustained full thickness burns over 70% of the face, anterior & posterior chest, & upper and lower extremities bilaterally. Which of the following findings should the nurse report to the provider immediately? 66. A client presents to the emergency department with a history of vomiting and diarrhea for 3 days. The nurse should recognize that which of the following findings indicates fluid volume deficit? 67. A nurse is caring for a client who is diagnosed with increased intracranial pressure and is given mannitol (Osmitrol). The nurse should recognize that which of the following is an adverse affect of this medication and might require the medication to be discontinued? 68. A nurse is assessing a client who has pruritic macular rash and erythema over his trunk and forearms. While interviewing the client, which of the following questions should the nurse ask? 69. A nurse is providing emergency care to a client who fell from a ladder and has a suspected closed fracture of the distal radius of the arm. Identify the sequence the nurse should follow. 70. A nurse is caring for a client who had a left shoulder tendon repair and returned from the PACU 4hr ago. The PACU report included the following: urine output 100 mL/hr, blood pressure 120/76 mm Hg, SaO2 98%, and a pain rating of 2 on a pain scale of 0 to 10. Which of the following current findings should be reported to the provider? 71. A nurse is caring for a client who is 1 day post-op following a thoractomy. Which of the following findings indicates a tension pneumothorax? 72. A nurse is providing teaching about exercise for a client who had been diagnosed with osteoarthritis. Which of the following should the nurse include in the teaching? 73. A nurse is providing care for a client who has a spinal cord injury. A halo fixation device is applied to the client’s skull and attached with vertical bars to a padded plastic vest. Which of the following is the priority assessment for the client? 74. A nurse providing teaching to a client who has just been prescribed an oral iron supplement. Which of the following statements by the client indicates an understanding of the teaching? 75. A nurse is planning care for a client who is post-op following renal transplantation. Which of the following is the highest priority nursing intervention to include in the care plan to prevent complications? 76. A nurse is caring for a client with HIV. Which of the following findings indicates a positive response to the prescribed HIV treatment? 77. A nurse is performing pre-op teaching for a client scheduled to have a right modified radical mastectomy. Which of the following should the nurse include in the client’s plan of care? 78. A nurse is caring for a client who is newly diagnoses with hyperthyroidism. Which of the following is the highest priority assessment finding that the nurse should report to the provider? 79. A client presents to the clinic for a 1-week follow-up visit after hospitalization for heart failure. Based on the information in the chart, which of the following findings should the nurse report to the primary care provider? 80. A nurse is preparing a client with supraventricular tachycardia for elective cardioversion. Which of the following prescribed medications should the nurse instruct the client to withhold for 48 hr prior to the cardioversion procedure? 81. A newly licensed nurse is caring for a client diagnosed with MRSA. Which of the following statements by the nurse indicates a need for further teaching? 82. A nurse is assessing a client who has a history of status epilepticus and is having a seizure. Which of the following is the priority assessment? 83. A nurse is assisting a provider with a Tensilon test on a client who was previously diagnosed with myasthenia gravis. After administration of Tensilon, the client demonstrated increased muscle weakness and twitching. The nurse should conclude that the client is exhibiting which of the following conditions? 84. A nurse is planning care for a client who has been admitted with burn injuries and requires immediate subclavian access foe an estimated 32 to 4 weeks. The nurse should include interventions related to the insertion and care of which of the following central venous access devices? (you have to select in the photo) 85. A nurse is caring for a client with a peripherally inserted central catheter (PICC). Which of the following methods of PICC line management is appropriate? 86. A nurse is caring for a client admitted with dehydration. The client’s laboratory values indicate a potassium level of 2.8 mEq/L. IV potassium therapy has been started. Which of the following assessment findings has the highest priority? 87. A nurse is caring for a client receiving heparin for a pulmonary embolism. The nurse should plan to assess the client for which of the following during this treatment? 88. A nurse is caring for a client who is 8hr post-op following total hip arthroplasty. The client is unable to void on the bedpan. Which of the following interventions should the nurse take first? 89. A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Which of the following statements made by the client reflects understanding of the teaching? 90. A client is in the recovery room following an extracapsular cataract removal. Which of the following findings should the nurse recognize as indicative of a possible complication? [Show More]

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