ATI Capstone Med Surg Assessment 2

Capstone Med Surg Assessment 2 1. a nurse is planning care for a client who has Meniere's disease and his experiencing episodes of vertical. which of Following intervention should the nurse include in the plan of care ...

Capstone Med Surg Assessment 2 1. a nurse is planning care for a client who has Meniere's disease and his experiencing episodes of vertical. which of Following intervention should the nurse include in the plan of care? a. Maintain strict bed rest pg 75 b. Restrict fluid intake to the morning hours. c. Administer aspirin. d. Provide a low-sodium diet. 2. a nurse is assessing a client of possible exposure of HIV . Which of the following findings should the nurse identify as an early manifestation of HIV infection? a. Stomatitis b. Fatigue c. Wasting syndrome d. Lipodystroph 3. Play nurse is teaching a client about using continuous positive airway pressure (CPAP) device to treat obstructive sleep apnea . Which of the following information should the client include in the teaching? a. It delivers a preset amount of inspiratory pressure at the beginning of each breath pg 119?????? b. it has continuous adjustment feature that changes the airway pressure throughout thecycle c. it delivers a preset amount of airway pressure throughout the breathing cycle d. it delivers positive pressure at the end of each breath 4. A nurse is teaching a client about fecal cult blood testing (FOBT) for the screening of colorectal cancer. Which of the following statements should the nurse include in the teaching? a. "Your provider will use stool from your digital rectal examination to perform the test." b. "Your provider will prescribe a stimulant laxative prior to the procedure to evacuate the bowel." c. "You should begin annual fecal occult blood testing for colorectal cancer screening at 40 years old." d. "You should avoid taking corticosteroids prior to testing." 5. A nurse is preparing a client for a colonoscopy. Which of the following medication should the nurse anticipate the provider to prescribe as an anesthetic for the procedure? a. Propofol pg 303 b. Pancuronium c. Promethazine d. Pentoxifylline 6. A nurse is teaching a client who has hypertension about dietary modifications to help control blood pressure. Which of the following food choices should the nurse recommend as a best choice for the client to include in their diet? a. 1 packet of reconstituted dry onion soup b. 3 oz of lean cured ham c. 3 oz of chicken breast d. ½ cup of canned baked beans 7. A nurse is caring for a client who has rheumatoid arthritis and has been taking Prednisone. Which of the following finding should the nurse identify as an adverse effect of this medication? a. Weight loss b. hypoglycemia c. hypertension d. hyperkalemia 8. A nurse is caring for a client who has increased intracranial pressure (ICP ). Which of the following intervention should the nurse implement? a. Place several pillows behind the client's head b. place the client in a Sims position - per p. 83 of 2019 version, first intervention to decrease ICP is to elevate head to at least 30o c. keep the client's neck in a midline position d. maintain flexion of the client's hips at a 90 degree angle 9. A home health nurse is providing teaching to the family of a client who has a seizure disorder. Which of the following intervention should the nurse include in the teaching? a. Keep a padded tongue blade near the bedside. b. Place a pillow under the client's head while in bed during a seizure. c. Administer diazepam orally at the onset of seizures. d. Position the client on their side during a seizure pg 36 10. A nurse is assessing a client who has meningitis the nurse should identify which of the following findings as a positive kernig's sign? a. After stroking the lateral area of the foot, the client's toes contract and draw together. b. After hip flexion, the client is unable to extend their leg completely without pain pg 31 c. The client's voluntary movement is not coordinated. d. The client reports pain and stiffness when flexing their neck. 11. A nurse is providing discharge teaching to a client who has heart failure and a prescription for furosemide 20 mg PO two times daily. Which of the following instruction should the nurse include in the teaching? a. Monitor for increased blood pressure. b. Increase intake of high-potassium foods pg 207 c. Expect an increase in swelling in the hands and feet. d. Take the second dose at bedtime. 12. A nurse is teaching a client who has type 1 diabetes mellitus about hypoglycemia. Which of the following statements by the client indicates an understanding of the teaching? a. exercise reduces the risk for hypoglycemia b. I can skip my insulin when I don't eat c. I can drink 4 ounces of soda if my blood sugar is low d. diabetic pills don't cause hypoglycemia; Only insulin does 13. A nurse in a rural community center is providing education to a group of clients about first aid interventions for snake bites to prevent further injury. Which of the following instructions should the nurse include in the teaching? a. Apply an ice pack directly to the affected area b. Immobilize the affected extremity with a splint - p. 9, 2019 c. Place tourniquet above and below the affected area d. Elevate the affected extremity 14. A nurse is teaching a group of clients about the risk factors for osteoporosis. Which of the following should the nurse include as a risk factor for osteoporosis? a. Early menopause b. history of falls c. African American race d. obesity 15. A nurse is reviewing the medical record of a client who has unstable angina. Which of the following findings should the nurse report to the provider? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data). a. Breath sounds b. Temperature c. Blood pressure d. Creatine kinase 16. A nurse is providing discharge teaching to a client who is starting to take carbidopa /levodopa to treat Parkinson's disease. Which of the following instructions should the nurse include in the teaching? a. "This medication can cause your urine to turn a dark color." b. "Expect immediate relief after taking this medication." c. "Take the medication with a high-protein food." d. "Skip a dose of the medication if you experience dizziness." pg 42 17. A nurse is providing dietary teaching for a client who has chronic cholecystitis. Which of the following day each of the nurse recommend? a. Low-potassium diet b. High-fiber diet c. Low-fat diet pg 356 d. Low-sodium diet 18. A nurse is providing teaching to a client who is scheduled for an electroencephalogram (EEG). which of the following statements by the client indicates an understanding of the teaching? a. I should not wash my hair prior to the procedure b. I will receive a sedated 1 hour before the procedure c. I should avoid eating prior to the procedure VERSION 19. A nurse is providing discharge teaching to a client following a heart transplant. Which of the following information should the nurse include in the teaching? a. Immunosuppressant medication needs to be taken for up to 1 year b. Shortness of breath might be an indication of transplant rejection pg 209 c. the surgical site will heal in 3 to 4 weeks after surgery d. begin 45 min of moderate aerobic exercise per day following discharge 20. A nurse is caring for a client who has been experiencing repeated tonic clonic seizures over the course of 30 minutes. After maintaining the client's airway and turning the client on their side, which of the following medication should the nurse administer? a. Diazepam IV pg 38 b. Lorazepam P0 c. Diltiazem IV d. Clonazepam PO 21. The nurse is providing discharge instructions to a client who has GERD. Which of the following statements by the client demonstrates an understanding of the teaching? a. I should take my medicine with orange juice b. a bedtime snack will prevent heartburn c. I will lie down after meals d. I will limit activities that require bending at the waist 22. A nurse is caring for a client who is at high risk for iron deficiency anemia. Which of the following foods should the nurse instruct the client to increase in their diet? a. Yogurt b. apples c. raisins PER NUTRITION BOOK d. cheddar cheese 23. A nurse is caring for a client who has rights sided pneumothorax. Following chest tube insertion, which of the following findings indicates that the chest drainage system is functioning correctly? a. Gentle bubbling in the suction chamber PG 108 2019 VERSION b. crepitus around the insertion site osteoc. constant bubbling in the water seal chamber d. absence of breath sounds on the right side 24. A nurse is planning care for a client who has acute post streptococcal glomerulonephritis . Which of the following intervention should the nurse include in the client's plan? a. Encourage a high-protein diet for the client b. increase the client's fluid intake c. administer diuretics to the client - glomerulnophritis results in fluid retention (because kidneys can’t filter out well) (p. 402-403, 2019) d. Weigh client twice a week - wrong, should weigh daily 25. A nurse is caring for a client who has a peripheral inserted central catheter (PICC). For which of the following findings should the nurse notify the provider? a. The dressing was changed 7 days ago. b. The circumference of the client's upper arm has increased by 10% PG 175 c. The catheter has not been used in 8 hr. d. The catheter has been flushed with 10 mL of sterile saline after medication use. 26. The nurse is developing a plan of care for a client who will be placed in a Halo surgical repair cervical spine. Which of the following intervention should the nurse include in the plan? a. Inspect the pin site every 48 hr. b. Monitor the client's skin under the halo vest pg 474 c. Ensure two personnel hold the halo device when repositioning the client. d. Apply powder frequently to the client's skin under the vest to decrease itching. 27. A nurse is caring for a client who has syndrome of inappropriate anti diuretic hormone (SIADH) and is receiving 3% sodium chloride via continuous IV. which of the following laboratory findings should the nurse identify as an indication that the SIADH is resolving? a. Urine specific gravity 1.020 pg 284 says “Urine specific gravity: Decreased (1.002 to 1.004 in sodium loss; greater than 1.012 in SIADH)” so 1.020 means not resolving b. Sodium 119 mEq/L wrong bc when have SIADH will have hyponatrmia c. BUN 8 mg/dL d. Calcium 8.7 mg/dL pg 85; I think bc its an electrolyte that is norm range-I PUT THIS 28. A nurse is caring for a client who is receiving total parenteral nutrition (TPN ). which of the following findings should the nurse identify as a possible complication of TPN administration? a. Pitting edema of bilateral lower extremities b. hypoactive bowel sounds in all four quadrants c. weight is the same as the day before d. bilateral posterior lung sounds are diminished - I think it is this. TPN can result in fluid imbalance/hypervolemia (p. 311) 29. A nurse is assessing a client who has a heart rate of 40 /min. the client is diaphoretic and as chest pain period which of the following medication should the nurse plan to administer? a. Lidocaine for tachycard b. Adenosine c. Atropine------------pg 181 chart atropine, dopamine, and epi for bradycard less 60/min d. Verapamil 30. The nurse is teaching a group of assistive personnel (AP) about caring for clients who have Alzheimer's disease. Which of the following information should the nurse include in the teaching? a. Explain procedures in full detail to a client before initiating care b. limit a client’s activities to minimize emotional outburst c. speak clearly and loudly to a client who is unable to form words or sentences d. provide supervision to prevent a client from becoming injured or lost 31. A nurse at a provider’s office is interviewing a client who has multiple sclerosis and has been taking dantrolene for several months. Which of the following client statements should the nurse identify as an indication that the medication is effective? a. I don't have muscle spasms as frequently PG 46 2016 VERSION b. I haven't gotten any colds, even though it is flu season c. I feel like my nerve pain has improved d. it is easier to urinate now 32. A nurse is preparing to discharge a client who has a new diagnosis of chronic kidney disease (CKD). which of the following referral should the nurse plan to initiate? a. Respiratory therapy b. Hospice care c. Occupational therapy d. Dietary services pg 394 14. A nurse is caring for a client who has burn injuries covering their upper body and is concern about their altered appearance. Which of the following statements should the nurse make? a. It is okay to not want to touch the burned areas of your body b. cosmetic surgery should be performed within the next year to be effective c. reconstructive surgery can completely restore your previous appearance d. injuries it could be helpful for you to attend a support group for people who have burn 4. A nurse is providing teaching to a client who was newly diagnosed with nephrotic syndrome. Which of the following statements should indicate to the nurse that the client understands the teaching? a. I can expect swelling in my hands an on my face PER ATI PRE-ASSESS STUDY GUIDE b. the amount of protein in my blood is high c. I might have some pain and gas in my stomach from this condition d. I will use a soft bristle toothbrush so my gums don't bleed 10. A nurse is caring for a client who has dehydration. The client has a peripheral IV and has a prescription for an infusion of 0.9% sodium chloride 1000 mL with 40 mEq potassium chloride to infuse over 1 hr. Which of the following action should the nurse take first? a. Teach the client to report findings of IV extravasation b. evaluate the patency of the IV c. consult with the pharmacist about the prescription d. verify the prescription with the provider - can’t find in ATI, but google says KCl can cause vomiting/diarrhea, which you wouldn’t want if pt is already dehydrated 13. A nurse is admitting a client who has suspected appendicitis. Which of the following findings should the nurse report to the provider immediately? a. Distended, board-like abdomen b. WBC count 15,000 /mm3 c. rebound tenderness over McBurney’s point - concur, but can’t find it in ATI on Children ATI book pg 145 2019 e d. temperature 37.3 C (99.1 F ) expected 2. A nurse in an Emergency Department is caring for a client who sustained multiple injuries. The nurse observes client’s thorax moving inward during inspiration and outward during expiration. The nurse should suspect which of the following injuries? a. Flail chest PER PG 157 2019 VERSION b. Hemothorax c. Pulmonary contusion d. Pneumothorax 20. A nurse is assessing a client who has a sodium level of 122 mEq/L. which of the following findings should the nurse expect? a. Decrease deep-tendon reflexes b. positive Trousseau’s sign c. hypoactive bowel sounds d. sticky mucus membranes • A nurse is providing teaching to a client who is scheduled for electromyography (EMG). the nurse should include which of the following information in the teaching? a. "You will receive a fixed dose of radioisotope 2 hours before the procedure." b. "Momentary flushing will occur at the beginning of the procedure." c. "You should inform your provider if you are claustrophobic." d. "You should expect insertion of small needle electrodes into the muscles." pg 448 12. The nurse is providing discharge teaching for a client who has COPD about nutrition. Which of the following instruction should the nurse include? a. Eat three large meals daily b. consume high calorie foods c. limit caffeinated drinks to two per day d. drink fluids during meal time • A nurse is administering a blood transfusion to a client and suspects that the client is having an adverse reaction to the blood. Which of the following action should the nurse take first? a. Maintain IV access. b. Obtain the client's vital signs. c. Contact the provider. d. Stop the transfusion. • A nurse is providing discharge teaching to a client who has acute leukemia and received chemotherapy 12 hours ago. Which of the following instruction should the nurse include in the teaching (select all that apply ) a. Use an electric shaver pg 615 b. Avoid crowds. c. Take temperature weekly weekly didn’t sound right d. Consume a low-residue diet pg 615; not true (low residue is veg and fiber; but in leukemia- need to restrict) e. Monitor for bruising pg 616 • A nurse is caring for a client who has a new diagnosis of tuberculosis. Which of the following precautions should the nurse initiate to prevent transmission of the disease? o Contact precautions o Airborne precautions o Droplet precautions o Protective environment • A nurse is caring for a client who is hyperventilating and has the following abgs results PH 7.50, PACO2---29, HCO3---25. The nurse should recognize that the client has which of the following acid base imbalance? o Respiratory acidosis o Respiratory alkalosis o Metabolic acidosis o Metabolic alkalosis 5. A nurse is planning for a group of postoperative clients. Which of the following interventions should the nurse identify as the priority? a. Administer IV pain medication to a client who reports pain as a 6 on a scale of 0 to 10 b. administer oxygen to a client who has an oxygen saturation of 91% c. instructor client who is 1 hour postoperative about coughing and deep breathing exercises d. initiate an infusion of 0.9% sodium chloride for a client who has just had abdominal surgery 23. A nurse is planning care for a client who has acute pancreatitis. Which of the following intervention should the nurse include in the clients plan? (Select all that apply ) a. initiate insulin drip ??????????? Says “provide insulin as needs” b. monitor blood glucose levels pg 360 c. continue regular diet as tolerated d. maintain NPO status until pain-free e. manage acute pain 7. A nurse is caring for a client who is to undergo in liver biopsy. Which of the following instruction should the nurse provide to the client following the procedure? a. Lie on your left side b. lie on your right side PG 366 2019 VERSION c. increase your fluid intake d. decrease your fluid intake A nurse is assessing a client who has permanent spinal cord injury and is scheduled for discharge. which of the following client statement indicates the client is coping efficiently? • "I would like to play wheelchair basketball. When I get stronger, I think I'll look for a league." • "I'm glad I'll only be in this wheelchair temporarily. I can't wait to get back to running." • "I'm so upset that this happened to me. What did I do to deserve this, and why am I not getting better?" • "I feel like I'll never be able to do anything that I want to again. All I am is a burden to my family." • The nurse is caring for a client who has chronic kidney disease. Which of the following diet should the nurse anticipate the provider to prescribe? o 4 g sodium diet o Potassium-restricted diet o High-phosphorous diet o High-protein diet the nurse is caring for a client who is traumatic brain injury period which of the following binding should indicate to the nurse the need for Immediate intervention? Axillary temperature 37.2° C (99° F) Apical pulse 100/min Respiratory rate 30/min Blood pressure 140/84 mm Hg