![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/7a82a6225f6d3f68f3bdc1f0713b84c5\/html\/bg1.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzdhODJhNjIyNWY2ZDNmNjhmM2JkYzFmMDcxM2I4NGM1L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDY1MTE4OH19fV19&Signature=Nm5j6nzWI8mAjM~7Ak-06yFbBxkC6Z2Pc0eVkt8L0RoaK8Vf7ALRCgA5X9d1QtcChxq2ApitqDcU3Db44Tah6k7jR~4Mzuy1J1baBRccECVWNnVq~aanoO28qxLZHLBw8~N4noOQ4QkVwIuipXw7nFonLSVJ~KSlyx8xs2nxqh74shH2XMtuPZIEktPRDqw54EHeHCf6avszC3W5FWMgHlZQDdxyBZ-3TCjK0dYCEZd6SzJ5yLj7VX77t7EOA~-1ak7VZHip0EL0naCt1JU6~yRawmAQMPveZrfoQWEwcnHjuo-PSqyVBAZUChpdoygMmIBqywjVa1wFLyrFZy~cxw__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n<\/p>\n\n\n\n
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n
1\u2026.A nurse in a burn treatment center is caring for a client who is admitted with<\/p>\n\n\n\n
severe burns to both lower extremities and is scheduled for an escharotomy. The<\/p>\n\n\n\n
client’s spouse asks the nurse what the procedure entails. Which of the following<\/p>\n\n\n\n
nursing statements is appropriate?<\/p>\n\n\n\n
Large incisions will be made in the eschar to improve circulation.<\/p>\n\n\n\n
Rational<\/p>\n\n\n\n
An escharotomy is a surgical incision made to release pressure and improve<\/p>\n\n\n\n
circulation in a part of the body that has a deep burn and is experiencing excessive<\/p>\n\n\n\n
swelling. Burn injuries that encircle a body part, such as an arm or the chest, can<\/p>\n\n\n\n
cause swelling and tightness in the affected area, resulting in reduced circulation.<\/p>\n\n\n\n
Making surgical incisions into the burned tissue allows the skin to expand, reduces<\/p>\n\n\n\n
tightness and pressure, and improves circulation.<\/p>\n\n\n\n
2\u2026. A nurse in a clinic is interviewing a client who has a possible diagnosis of<\/p>\n\n\n\n
endometriosis. Which of the following findings in the client’s history should the<\/p>\n\n\n\n
nurse recognize as consistent with a diagnosis of endometriosis?<\/p>\n\n\n\n
Dysmenorrhea that is unresponsive to NSAIDs.<\/p>\n\n\n\n
Rational<\/p>\n\n\n\n
Endometriosis is a condition in which the type of tissue that lines the uterus<\/p>\n\n\n\n
implants in locations outside the uterus. This typically causes pelvic pain<\/p>\n\n\n\n
around the time of the menstrual period but can cause pain at other times in<\/p>\n\n\n\n
the cycle. The discomfort is often unrelieved by the use of NSAIDs.<\/p>\n\n\n\n
3\u2026. A rehabilitation nurse is caring for a client who has had a spinal cord injury<\/p>\n\n\n\n
that resulted in paraplegia. After a week on the unit, the nurse notes that the<\/p>\n\n\n\n
client is withdrawn and increasingly resistant to rehabilitative efforts by the staff.<\/p>\n\n\n\n
Which of the following actions should the nurse take?<\/p>\n\n\n\n
Establish a plan of care with the client that sets attainable goals.<\/p>\n\n\n\n
Rational<\/p>\n\n\n\n
The nurse should develop a plan of care for this client with mutually set goals. This<\/p>\n\n\n\n
action invests the client in the rehabilitation process, which encourages feelings of<\/p>\n\n\n\n
ownership for it, and sees the goals as more attainable<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/7a82a6225f6d3f68f3bdc1f0713b84c5\/html\/bg2.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzdhODJhNjIyNWY2ZDNmNjhmM2JkYzFmMDcxM2I4NGM1L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDY1MTE4OH19fV19&Signature=Nm5j6nzWI8mAjM~7Ak-06yFbBxkC6Z2Pc0eVkt8L0RoaK8Vf7ALRCgA5X9d1QtcChxq2ApitqDcU3Db44Tah6k7jR~4Mzuy1J1baBRccECVWNnVq~aanoO28qxLZHLBw8~N4noOQ4QkVwIuipXw7nFonLSVJ~KSlyx8xs2nxqh74shH2XMtuPZIEktPRDqw54EHeHCf6avszC3W5FWMgHlZQDdxyBZ-3TCjK0dYCEZd6SzJ5yLj7VX77t7EOA~-1ak7VZHip0EL0naCt1JU6~yRawmAQMPveZrfoQWEwcnHjuo-PSqyVBAZUChpdoygMmIBqywjVa1wFLyrFZy~cxw__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n
4\u2026. A nurse is reviewing the laboratory data of a client who has acute pancreatitis.<\/p>\n\n\n\n
The nurse should expect to find an elevation of which of following values?<\/p>\n\n\n\n
Amylase<\/p>\n\n\n\n
Rational<\/p>\n\n\n\n
Amylase is an enzyme that changes complex sugars into simple sugars that can be<\/p>\n\n\n\n
used by the body. It is produced by the pancreas and salivary glands and released<\/p>\n\n\n\n
into the mouth, stomach, and intestines to aid in digestion. The amylase level of a<\/p>\n\n\n\n
client who has acute pancreatitis usually increases within 12 to 24 hr and can<\/p>\n\n\n\n
remain elevated for 2 to 3 days.<\/p>\n\n\n\n
5\u2026.A nurse is caring for a client who has suspected cholecystitis. The nurse should<\/p>\n\n\n\n
expect the client’s urine to appear which of the following colors?<\/p>\n\n\n\n
Dark and foamy<\/p>\n\n\n\n
Rational<\/p>\n\n\n\n
The nurse should expect the client to have dark and foamy urine, which indicates<\/p>\n\n\n\n
the kidneys are filtering excess bilirubin from the blood.<\/p>\n\n\n\n
6\u2026.A nurse is caring for an older adult client who has rheumatoid arthritis (RA)<\/p>\n\n\n\n
and is taking aspirin 650 mg every 4 hours. Which of the following diagnostic<\/p>\n\n\n\n
tests should the nurse monitor to evaluate the effectiveness of this medication?<\/p>\n\n\n\n
Erythrocyte sedimentation rate (ESR)<\/p>\n\n\n\n
Rational<\/p>\n\n\n\n
Rheumatoid arthritis is a chronic inflammatory disease. ESR is useful in detecting<\/p>\n\n\n\n
andmonitoringtissueinflammationinclients withRA.Asthediseaseimproves<\/p>\n\n\n\n
the ESR decreases.<\/p>\n\n\n\n
7\u2026.A nurse is providing dietary teaching to a client who has a history of recurring<\/p>\n\n\n\n
calcium oxalate kidney stones. Which of the following instructions should the<\/p>\n\n\n\n
nurse include in the teaching?<\/p>\n\n\n\n
Drink 3 L of fluid every day.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/7a82a6225f6d3f68f3bdc1f0713b84c5\/html\/bg3.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzdhODJhNjIyNWY2ZDNmNjhmM2JkYzFmMDcxM2I4NGM1L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDY1MTE4OH19fV19&Signature=Nm5j6nzWI8mAjM~7Ak-06yFbBxkC6Z2Pc0eVkt8L0RoaK8Vf7ALRCgA5X9d1QtcChxq2ApitqDcU3Db44Tah6k7jR~4Mzuy1J1baBRccECVWNnVq~aanoO28qxLZHLBw8~N4noOQ4QkVwIuipXw7nFonLSVJ~KSlyx8xs2nxqh74shH2XMtuPZIEktPRDqw54EHeHCf6avszC3W5FWMgHlZQDdxyBZ-3TCjK0dYCEZd6SzJ5yLj7VX77t7EOA~-1ak7VZHip0EL0naCt1JU6~yRawmAQMPveZrfoQWEwcnHjuo-PSqyVBAZUChpdoygMmIBqywjVa1wFLyrFZy~cxw__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n
Rational<\/p>\n\n\n\n
The nurse should instruct the client to drink at least 3 to 4 L of fluid every day to<\/p>\n\n\n\n
dilute the urine and reduce the risk for stone formation.<\/p>\n\n\n\n
8\u2026.A nurse is assessing a client who has disseminated intravascular coagulation<\/p>\n\n\n\n
(DIC). Which of the following findings should the nurse expect?<\/p>\n\n\n\n
Excessive thrombosis and bleeding<\/p>\n\n\n\n
Rational<\/p>\n\n\n\n
The nurse should expect excessive thrombosis and bleeding of mucous<\/p>\n\n\n\n
membranes because both DIC impairs both coagulation and anticoagulation<\/p>\n\n\n\n
pathways.<\/p>\n\n\n\n
9\u2026.A nurse is caring for a middle adult client who has just received the diagnosis<\/p>\n\n\n\n
of endometrial cancer. In taking a nursing history, which of the following<\/p>\n\n\n\n
manifestations is likely to be reported by this client?<\/p>\n\n\n\n
Postmenopausal bleeding<\/p>\n\n\n\n
Rational<\/p>\n\n\n\n
Endometrial cancer involves cancerous growth of the endometrium (lining of<\/p>\n\n\n\n
the uterus). The most common manifestation of endometrial cancer is abnormal<\/p>\n\n\n\n
uterine bleeding, including postmenopausal bleeding and bleeding between<\/p>\n\n\n\n
normal periods in premenopausal women.<\/p>\n\n\n\n
10\u2026A nurse is giving a presentation to a community group about preventing<\/p>\n\n\n\n
atherosclerosis. Which of the following should the nurse include as a modifiable<\/p>\n\n\n\n
risk factor for this disorder? (Select all that apply.)<\/p>\n\n\n\n
Hypercholesterolemia<\/p>\n\n\n\n
Hypertension<\/p>\n\n\n\n
Obesity<\/p>\n\n\n\n
Smoking<\/p>\n\n\n\n
11\u2026A nurse is admitting a client who has active tuberculosis to a room on a<\/p>\n\n\n\n
medical-surgical unit. Which of the following room assignments should the<\/p>\n\n\n\n
nurse make for the client?<\/p>\n\n\n\n
A room with air exhaust directly to the outdoor environment<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/7a82a6225f6d3f68f3bdc1f0713b84c5\/html\/bg4.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzdhODJhNjIyNWY2ZDNmNjhmM2JkYzFmMDcxM2I4NGM1L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDY1MTE4OH19fV19&Signature=Nm5j6nzWI8mAjM~7Ak-06yFbBxkC6Z2Pc0eVkt8L0RoaK8Vf7ALRCgA5X9d1QtcChxq2ApitqDcU3Db44Tah6k7jR~4Mzuy1J1baBRccECVWNnVq~aanoO28qxLZHLBw8~N4noOQ4QkVwIuipXw7nFonLSVJ~KSlyx8xs2nxqh74shH2XMtuPZIEktPRDqw54EHeHCf6avszC3W5FWMgHlZQDdxyBZ-3TCjK0dYCEZd6SzJ5yLj7VX77t7EOA~-1ak7VZHip0EL0naCt1JU6~yRawmAQMPveZrfoQWEwcnHjuo-PSqyVBAZUChpdoygMmIBqywjVa1wFLyrFZy~cxw__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n
Rational<\/p>\n\n\n\n
A room with air exhaust directly to the outside environment eliminates<\/p>\n\n\n\n
contamination of other client-care areas. This type of ventilation system is<\/p>\n\n\n\n
referred to as an airborne infection isolation room.<\/p>\n\n\n\n
12\u2026A nurse is caring for a client who has Cushing’s syndrome. Which of the<\/p>\n\n\n\n
following interventions should the nurse expect to perform? (Select all that apply.)<\/p>\n\n\n\n
Assess blood glucose level<\/p>\n\n\n\n
Assess for neck vein distention<\/p>\n\n\n\n
Incorrect. Monitor for an irregular heart rate<\/p>\n\n\n\n
Incorrect. Monitor for postural hypotension<\/p>\n\n\n\n
Weigh the client daily<\/p>\n\n\n\n
13\u2026A nurse is teaching a client about risk factors for osteoporosis. Which of the<\/p>\n\n\n\n
following factors should the nurse include in the teaching? (Select all that apply.)<\/p>\n\n\n\n
Sedentary lifestyle<\/p>\n\n\n\n
Incorrect. Obesity<\/p>\n\n\n\n
Aging<\/p>\n\n\n\n
Caffeine intake<\/p>\n\n\n\n
Secondhand smoke<\/p>\n\n\n\n
Sedentary lifestyle is correct. Immobility depletes bone.<\/p>\n\n\n\n
Obesity is incorrect. Women who are obese have a greater capacity for storing<\/p>\n\n\n\n
estrogen to help maintain acceptable levels of calcium.<\/p>\n\n\n\n
Aging is correct. Women lose bone due to estrogen depletion after menopause.<\/p>\n\n\n\n
Caffeine intake is correct. Excessive caffeine intake causes calcium loss in the<\/p>\n\n\n\n
urine.<\/p>\n\n\n\n
Secondhand smoke is correct. Smoking is a risk factor for osteoporosis, both<\/p>\n\n\n\n
active and passive (secondhand) smoking.<\/p>\n\n\n\n
14\u2026A nurse is caring for a client who has a history of exposure to TB and<\/p>\n\n\n\n
symptoms of night sweats and hemoptysis. Which of the following tests should<\/p>\n\n\n\n
the nurse realize is the most reliable to confirm the diagnosis of active pulmonary<\/p>\n\n\n\n
TB?<\/p>\n\n\n\n
Sputum culture for acid-fast<\/p>\n\n\n\n
bacillus Rational<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/7a82a6225f6d3f68f3bdc1f0713b84c5\/html\/bg5.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzdhODJhNjIyNWY2ZDNmNjhmM2JkYzFmMDcxM2I4NGM1L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDY1MTE4OH19fV19&Signature=Nm5j6nzWI8mAjM~7Ak-06yFbBxkC6Z2Pc0eVkt8L0RoaK8Vf7ALRCgA5X9d1QtcChxq2ApitqDcU3Db44Tah6k7jR~4Mzuy1J1baBRccECVWNnVq~aanoO28qxLZHLBw8~N4noOQ4QkVwIuipXw7nFonLSVJ~KSlyx8xs2nxqh74shH2XMtuPZIEktPRDqw54EHeHCf6avszC3W5FWMgHlZQDdxyBZ-3TCjK0dYCEZd6SzJ5yLj7VX77t7EOA~-1ak7VZHip0EL0naCt1JU6~yRawmAQMPveZrfoQWEwcnHjuo-PSqyVBAZUChpdoygMmIBqywjVa1wFLyrFZy~cxw__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n
Although the Mantoux (skin test) and the chest x-ray may be useful screening<\/p>\n\n\n\n
tools for TB, the presence of acid-fast bacillus noted in the client’s sputum,<\/p>\n\n\n\n
secretions, or tissues is the only method that can actually confirm the diagnosis.<\/p>\n\n\n\n
15\u2026A nurse is caring for a client who has emphysema. Which of the following<\/p>\n\n\n\n
findings should the nurse expect to assess in this client? (Select all that<\/p>\n\n\n\n
apply.)<\/p>\n\n\n\n
Dyspnea<\/p>\n\n\n\n
Incorrect. Bradycardia<\/p>\n\n\n\n
Barrel chest<\/p>\n\n\n\n
Clubbing of the fingers<\/p>\n\n\n\n
Incorrect. Deep respirations<\/p>\n\n\n\n
Rational<\/p>\n\n\n\n
Dyspnea is correct.Emphysema is a lung disease involving damage to the alveoli<\/p>\n\n\n\n
in which they become weakened and collapse. Dyspnea is seen in clients with<\/p>\n\n\n\n
emphysema as the lungs try to increase the amount of oxygen available to the<\/p>\n\n\n\n
tissues.<\/p>\n\n\n\n
Bradycardia is incorrect. With emphysema, the heart rate will increase as the<\/p>\n\n\n\n
heart tries to compensate for less oxygen to the tissues.<\/p>\n\n\n\n
Barrel chest is correct. Clients with emphysema lose lung elasticity; the<\/p>\n\n\n\n
diaphragm becomes permanently flattened by hyperinflation of the lungs; the<\/p>\n\n\n\n
muscles of the rib cage become rigid; and the ribs flare outward. This produces<\/p>\n\n\n\n
the barrel chest typical of emphysema clients.<\/p>\n\n\n\n
Clubbing of the fingers is correct. Clubbing results from chronic low arterial-<\/p>\n\n\n\n
oxygen levels. The tips of the fingers enlarge and the nails become extremely<\/p>\n\n\n\n
curved from front to back.<\/p>\n\n\n\n
Deep respirations is incorrect. Clients with emphysema lose lung elasticity and<\/p>\n\n\n\n
have muscle fatigue; consequently, respirations become increasingly shallow.<\/p>\n\n\n\n
16\u2026A nurse in an emergency room is caring a the client who sustained partial-<\/p>\n\n\n\n
thickness burns to both lower legs, chest, face, and both forearms. Which of the<\/p>\n\n\n\n
following is the priority action the nurse should take?<\/p>\n\n\n\n
Inspect the mouth for signs of inhalation injuries.<\/p>\n\n\n\n
Rational<\/p>\n\n\n\n
Since the client sustained burns to the chest and face, there is a possibility that<\/p>\n\n\n\n
flames and smoke from the client’s burning clothes could have caused an<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/7a82a6225f6d3f68f3bdc1f0713b84c5\/html\/bg6.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzdhODJhNjIyNWY2ZDNmNjhmM2JkYzFmMDcxM2I4NGM1L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDY1MTE4OH19fV19&Signature=Nm5j6nzWI8mAjM~7Ak-06yFbBxkC6Z2Pc0eVkt8L0RoaK8Vf7ALRCgA5X9d1QtcChxq2ApitqDcU3Db44Tah6k7jR~4Mzuy1J1baBRccECVWNnVq~aanoO28qxLZHLBw8~N4noOQ4QkVwIuipXw7nFonLSVJ~KSlyx8xs2nxqh74shH2XMtuPZIEktPRDqw54EHeHCf6avszC3W5FWMgHlZQDdxyBZ-3TCjK0dYCEZd6SzJ5yLj7VX77t7EOA~-1ak7VZHip0EL0naCt1JU6~yRawmAQMPveZrfoQWEwcnHjuo-PSqyVBAZUChpdoygMmIBqywjVa1wFLyrFZy~cxw__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n
inhalation injury. The nurse should inspect the mouth and throat for soot and<\/p>\n\n\n\n
swelling. Using the airway, breathing, circulation (ABC) priority-setting<\/p>\n\n\n\n
framework, is the priority concern at this time<\/p>\n\n\n\n
17\u2026A nurse is planning care for a client who is being treated with<\/p>\n\n\n\n
chemotherapy and radiation for metastatic breast cancer, and who has<\/p>\n\n\n\n
neutropenia. The nurse should include which of the following restrictions inthe<\/p>\n\n\n\n
client’s plan of care?<\/p>\n\n\n\n
Fresh flowers and potted plants in the room<\/p>\n\n\n\n
18\u2026A nurse is preparing dietary instructions for a client who has episodes of<\/p>\n\n\n\n
biliary colic from chronic cholecystitis. Which of the following instructions should<\/p>\n\n\n\n
the nurse include in the teaching plan?<\/p>\n\n\n\n
Avoid foods high in fat.<\/p>\n\n\n\n
Rational<\/p>\n\n\n\n
The nurse should instruct the client to follow a low-fat diet to decrease episodes<\/p>\n\n\n\n
of biliary colic. A client who has chronic cholecystitis has intolerance to fatty<\/p>\n\n\n\n
foods<\/p>\n\n\n\n
19\u2026A nurse is providing preoperative teaching for a client who is scheduled for a<\/p>\n\n\n\n
gastrectomy. Which of the following information regarding prevention of<\/p>\n\n\n\n
postoperative complications should the nurse include in in the teaching?<\/p>\n\n\n\n
Instruct the client about the use of a sequential compression device.<\/p>\n\n\n\n
Rational<\/p>\n\n\n\n
The nurse should instruct the client about the use of a sequential compression<\/p>\n\n\n\n
device to prevent deep-vein thrombosis, a postoperative complication.<\/p>\n\n\n\n
20\u2026A nurse is caring for a middle adult female client who reports that her<\/p>\n\n\n\n
menstrual periods have become irregular and she has been having hot flashes.<\/p>\n\n\n\n
The nurse should expect the client to have which of the following manifestations<\/p>\n\n\n\n
associated with early menopause?<\/p>\n\n\n\n
Dryness with intercourse<\/p>\n\n\n\n
Rational<\/p>\n\n\n\n
Menopause, the cessation of a woman’s menstrual periods, occurs when the<\/p>\n\n\n\n
ovaries stop making estrogen. Because of the changes in the vagina, some women<\/p>\n\n\n\n
can have dryness, discomfort, or pain during sexual intercourseDocument continues below<\/p>\n\n\n\n
Discover more from:<\/strong><\/p>\n\n\n\n Medical Surgical Nursing 1 (NUR 2037C)<\/a><\/strong>(NUR 2037C)<\/p>\n\n\n\n 96 documentsGo to course<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n 21\u2026During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion<\/p>\n\n\n\n on a client’s chest. The lesion is raised and flesh-colored with pearly white<\/p>\n\n\n\n borders. The nurse should recognize that this finding is suggestive of which of the<\/p>\n\n\n\n following types of skin cancer?<\/p>\n\n\n\n Basal cell carcinoma<\/p>\n\n\n\n Rational<\/p>\n\n\n\n A basal cell tumor usually begins as a small, waxy nodule with rolled, translucent,<\/p>\n\n\n\n pearly borders. Telangiectatic vessels can also be present. As a basal cell tumor<\/p>\n\n\n\n grows, it can undergo central ulceration.<\/p>\n\n\n\n 22\u2026A nurse is teaching a group of newly license nurses on effective techniques for<\/p>\n\n\n\n counseling clients about sexually transmitted infections (STIs). Which of the<\/p>\n\n\n\n following statements should the nurse include in the teaching?<\/p>\n\n\n\n Ask about the client’s exposure to any past or present STIs.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse should assess the client exposure to any past or present STIs and any<\/p>\n\n\n\n treatment taken.<\/p>\n\n\n\n 23\u2026A nurse is teaching a client who has hepatitis A about preventing<\/p>\n\n\n\n transmission of the virus. Which of the following strategies should the nurse<\/p>\n\n\n\n include in the teaching?<\/p>\n\n\n\n Practice effective hand hygiene.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Effective hand hygiene\u2014along with immunization, sewer sanitation, and a safe<\/p>\n\n\n\n water supply\u2014are the most effective strategies for preventing the transmission of<\/p>\n\n\n\n hepatitis A.<\/p>\n\n\n\n 24\u2026A nurse is assessing a client who has fluid overload. Which of the following<\/p>\n\n\n\n findings should the nurse expect? (Select all that apply.)<\/p>\n\n\n\n Increased heart rate<\/p>\n\n\n\n Increased blood pressure<\/p>\n\n\n\n Increased respiratory rate<\/p>\n\n\n\n Incorrect. Increase hematocrit<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n Incorrect. Increased temperature<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Increased heart rate is correct.The nurse should expect the client who has fluid<\/p>\n\n\n\n volume excess to have tachycardia and increased cardiac contractility in<\/p>\n\n\n\n response to the excess fluid.<\/p>\n\n\n\n Increased blood pressure is correct. The nurse should expect the client who has<\/p>\n\n\n\n fluid volume excess to have increased blood pressure and bounding pulse in<\/p>\n\n\n\n response to the excess fluid.<\/p>\n\n\n\n Increased respiratory rate is correct. The nurse should expect the client who has<\/p>\n\n\n\n fluid volume excess to have increase in respiratory rate and moist crackles heard<\/p>\n\n\n\n in lungs.<\/p>\n\n\n\n Increased hematocrit is incorrect. The nurse should expect the client who has<\/p>\n\n\n\n fluid volume deficit to have an elevated hematocrit because of<\/p>\n\n\n\n hemoconcentration.<\/p>\n\n\n\n Increase temperature is incorrect. The nurse should expect the client who has<\/p>\n\n\n\n fluid volume deficit to have an increase in temperature due to fluid loss.<\/p>\n\n\n\n 25\u2026A staff nurse is teaching a client who has Addison’s disease about the disease<\/p>\n\n\n\n process. The client asks the nurse what causes Addison’s disease. Which of the<\/p>\n\n\n\n following responses should the nurse make?<\/p>\n\n\n\n It is caused by the lack of production of aldosterone by the adrenal gland.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Addison’s disease is caused by a lack of production of the adrenocorticotropic<\/p>\n\n\n\n hormones (cortisol and aldosterone) by the adrenal gland<\/p>\n\n\n\n 26\u2026FLAG<\/p>\n\n\n\n A nurse is providing discharge teaching for a client who is postoperative following<\/p>\n\n\n\n a simple mastectomy. The client is to begin outpatient radiation therapy the next<\/p>\n\n\n\n day. Which of the following instructions about maintaining skin integrity should<\/p>\n\n\n\n the nurse include?<\/p>\n\n\n\n Do not apply heat to the area of irradiation.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n This instruction will help the client avoid tissue damage. Radiated tissue becomes<\/p>\n\n\n\n thinner and might lack tissue receptors that would otherwise alert the client to a<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n potential burn injury. When outdoors in sunlight, the client should wear protective<\/p>\n\n\n\n clothing over the area of irradiation.<\/p>\n\n\n\n 27\u2026A nurse is teaching a newly licensed nurse about the purpose of a CA 125 test.<\/p>\n\n\n\n Which of the following statements should the nurse include in the teaching?<\/p>\n\n\n\n A CA 125 test is used to monitor a client’s progress during treatment of ovarian<\/p>\n\n\n\n cancer.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n CA 125 tests are useful in monitoring progress during and after treatment of<\/p>\n\n\n\n ovarian cancer<\/p>\n\n\n\n 28\u2026A nurse is teaching a client about the seven warning signs of cancer. Which<\/p>\n\n\n\n of the following signs shouldthe nurse include asmanifestations of cancer?<\/p>\n\n\n\n (Select all that apply.)<\/p>\n\n\n\n A non-healing sore<\/p>\n\n\n\n Incorrect. Bloating<\/p>\n\n\n\n Change in bowel pattern<\/p>\n\n\n\n Change in moles<\/p>\n\n\n\n Nagging cough<\/p>\n\n\n\n 29\u2026A nurse is monitoring a client who was admitted with a severe burn injury and<\/p>\n\n\n\n is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in<\/p>\n\n\n\n which of the following findings as an indication of adequate fluid replacement?<\/p>\n\n\n\n Heart rate<\/p>\n\n\n\n Rational<\/p>\n\n\n\n When a client’s circulating fluid volume is low, the heart rate increases to maintain<\/p>\n\n\n\n adequate blood pressure. Therefore, the nurse should identify a decrease in heart<\/p>\n\n\n\n rate as in indication of adequate fluid replacement<\/p>\n\n\n\n 30\u2026A nurse is caring for a client who has myelosuppression after receiving<\/p>\n\n\n\n chemotherapy. The nurse should monitor the client for which of the following<\/p>\n\n\n\n adverse effects?<\/p>\n\n\n\n Bleeding from the gums<\/p>\n\n\n\n Rational<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n Bleeding from the gums is directly related to myelosuppression due to inhibited<\/p>\n\n\n\n bone marrow production of blood cells and platelets.<\/p>\n\n\n\n 31\u2026A nurse is providing discharge teaching to a client who has a new<\/p>\n\n\n\n arteriovenous fistula in the right forearm. Which of the following manifestations<\/p>\n\n\n\n should the nurse include in the teaching as a possible indication of venous<\/p>\n\n\n\n insufficiency?<\/p>\n\n\n\n Cold and numb numbness distal to the fistula site<\/p>\n\n\n\n Pallor and numbness distal to the fistula site are possible indicators of venous<\/p>\n\n\n\n insufficiency and should be immediately reported to the provider.<\/p>\n\n\n\n 32\u2026A nurse is planning an educational program about basal cell carcinoma. Which<\/p>\n\n\n\n of the following information should the nurse plan to include?<\/p>\n\n\n\n Basal cell carcinoma has a low incidence of metastasis.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Basal cell carcinoma is a localized lesion that seldom metastasizes.<\/p>\n\n\n\n 33\u2026A nurse receives a unit of packed RBCs from a blood bank and notes that the<\/p>\n\n\n\n time is 1130. The nurse should begin the infusion at which of the following<\/p>\n\n\n\n times? As soon as the nurse can prepare the client and the administration set<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse should infuse the blood as soon as possible and complete the<\/p>\n\n\n\n procedure within 4 hr.<\/p>\n\n\n\n 34\u2026A nurse is teaching self-management to a client who has hepatitis B. Which<\/p>\n\n\n\n of the following Instructions should the nurse include in the teaching?<\/p>\n\n\n\n Rest frequently throughout the day.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Limiting activity is usually recommended until the symptoms of hepatitis have<\/p>\n\n\n\n subsided. The nurse should recommend the client rest frequently throughout the<\/p>\n\n\n\n day to reduce the metabolic demands upon the liver and decrease energy<\/p>\n\n\n\n demands.<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n 35\u2026A nurse is caring for a client who has HIV. Which of the following laboratory<\/p>\n\n\n\n values is the nurse’s priority?<\/p>\n\n\n\n CD4-T-cell count 180 cells\/mm3<\/p>\n\n\n\n Rational<\/p>\n\n\n\n A CD4-T-cell count of less than 180 cells\/mm3 indicates that the client is severely<\/p>\n\n\n\n immunocompromised and is at high risk for infection. Therefore, this value is the<\/p>\n\n\n\n priority for the nurse to report to the provider<\/p>\n\n\n\n 36\u2026A nurse is instructing a client how to decrease the nausea associated<\/p>\n\n\n\n with chemotherapy and radiation. Which of the following statements<\/p>\n\n\n\n indicates an understanding of the teaching?<\/p>\n\n\n\n I will eat foods that are served at room temperature.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse should instruct the client to eat foods served at room temperature or<\/p>\n\n\n\n chilled. Foods served hot may contribute to nausea.<\/p>\n\n\n\n 37\u2026A nurse is reviewing discharge instructions with a client following a right<\/p>\n\n\n\n cataract extraction. Which of the following instructions should the nurse include?<\/p>\n\n\n\n Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse should instruct the client to avoid activities that increase intraocular<\/p>\n\n\n\n pressure. Therefore, the nurse should instruct the client to avoid lifting anything<\/p>\n\n\n\n heavier than 4.5 kg (10 lb) for 1 week following surgery.<\/p>\n\n\n\n 38\u2026A nurse is teaching about adverse effects of anastrozole with a client who has<\/p>\n\n\n\n advanced breast cancer and is postmenopausal. Which of the following adverse<\/p>\n\n\n\n effects should the nurse recommend the client report to the provider?<\/p>\n\n\n\n Musculoskeletal pain<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The client who is experiencing musculoskeletal pain should notify the provider.<\/p>\n\n\n\n Musculoskeletal pain is a common adverse effect that affects 50% of clients that<\/p>\n\n\n\n is possibly caused from estrogen deprivation<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n 39\u2026A nurse is reviewing the laboratory findings for a client who developed fat<\/p>\n\n\n\n embolism syndrome (FES) following a fracture. Which of the following laboratory<\/p>\n\n\n\n findings should the nurse expect?<\/p>\n\n\n\n Decreased serum calcium level<\/p>\n\n\n\n Rational<\/p>\n\n\n\n A decreased serum calcium level is an expected finding for FES, although the<\/p>\n\n\n\n reason for this finding is unknown.<\/p>\n\n\n\n 40\u2026A client is receiving treatment for stage IV ovarian cancer and asks the nurse<\/p>\n\n\n\n to discuss her prognosis. The client plans to have aggressive surgical, radiation,<\/p>\n\n\n\n and chemotherapy treatments. Which of the following prognoses should the<\/p>\n\n\n\n nurse discuss with the client?<\/p>\n\n\n\n Poor<\/p>\n\n\n\n Rational<\/p>\n\n\n\n At this advanced stage, the prognosis for ovarian cancer is poor. Ovarian cancer is<\/p>\n\n\n\n the leading cause of death from female reproductive cancers. Survival rates are<\/p>\n\n\n\n low because it is not often discovered until its late stages.<\/p>\n\n\n\n 41\u2026A nurse is providing teaching to a client who has had a total abdominal<\/p>\n\n\n\n hysterectomy and bilateral salpingo-oophorectomy for uterine cancer. Which of<\/p>\n\n\n\n the following instructions should the nurse include in the teaching?<\/p>\n\n\n\n Artificial lubrication can be used to treat vaginal itching and dryness.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse should instruct the client that atrophic vaginal changes occur due to the<\/p>\n\n\n\n loss of estrogen postoperatively and can also cause pain and dryness during sexual<\/p>\n\n\n\n intercourse. Artificial lubricants can reduce the manifestations associated with<\/p>\n\n\n\n diminished mucous production.<\/p>\n\n\n\n 42\u2026A nurse at a rehabilitation center is planning care for a client who had a left<\/p>\n\n\n\n hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the<\/p>\n\n\n\n following goals should the nurse include in the client’s rehabilitation program?<\/p>\n\n\n\n Establish the ability to communicate<\/p>\n\n\n\n effectively. Rational<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n A CVA is an interruption of the blood supply to any part of the brain, resulting in<\/p>\n\n\n\n damaged brain tissue. The left hemisphere is usually dominant for language.<\/p>\n\n\n\n Because this client had a left-side CVA, the nurse should anticipate the client will<\/p>\n\n\n\n have some degree of aphasia and will require speech therapy to establish<\/p>\n\n\n\n communication.<\/p>\n\n\n\n 43\u2026A nurse is teaching a client about the causes of osteoporosis. The nurse<\/p>\n\n\n\n should include which of the following types of medication therapy as a risk factor<\/p>\n\n\n\n for osteoporosis?<\/p>\n\n\n\n Thyroid hormones<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Long-term use of synthetic thyroid hormone, such as levothyroxine, can accelerate<\/p>\n\n\n\n bone loss.<\/p>\n\n\n\n 44\u2026A nurse is teaching a newly licensed nurse about gynecological examination.<\/p>\n\n\n\n Which of the following information should the nurse include in the teaching?<\/p>\n\n\n\n The urethral orifice is assessed by separating the labia minora.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The urethral orifice, clitoris, and vaginal orifice are examined for lesions,<\/p>\n\n\n\n inflammation, and discharge by separating the labia minora.<\/p>\n\n\n\n 45\u2026FLAG<\/p>\n\n\n\n A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which<\/p>\n\n\n\n of the following abnormalities on the client’s EKG should the nurse interpret as a<\/p>\n\n\n\n sign of hypokalemia?<\/p>\n\n\n\n Abnormally prominent U wave<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Although U waves are rare, their presence can be associated with hypokalemia,<\/p>\n\n\n\n hypertension and heart disease. For a client who has hypokalemia, the nurse<\/p>\n\n\n\n should monitor the EKG strip for a flattened T wave, prolonged PR interval,<\/p>\n\n\n\n prominent U wave, or ST depression.<\/p>\n\n\n\n 46\u2026A nurse is assessing a client who reports numbness and pain in his right palm,<\/p>\n\n\n\n index finger, and middle finger. The client reports working with a keyboard most of<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n the time while at work. The nurse suspects carpal tunnel syndrome. Which of<\/p>\n\n\n\n the following tests should the nurse request that the client perform?<\/p>\n\n\n\n Hold the wrist at a 90-degree flexion.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Carpal tunnel syndrome is the compression of the median nerve at the wrist.<\/p>\n\n\n\n The condition is common in people who perform repetitive motions of the hand<\/p>\n\n\n\n and wrist, such as typing. Tapping over the median nerve at the wrist may cause<\/p>\n\n\n\n pain to shoot from the wrist to the hand, andbending the wrist at a 90-degree<\/p>\n\n\n\n flexion will usually result in numbness, tingling, or weakness<\/p>\n\n\n\n 47\u2026A nurse is teaching a class about preventive care to clients who are at risk for<\/p>\n\n\n\n acquiring viral hepatitis. Which of the following information should the nurse<\/p>\n\n\n\n include in the presentation?<\/p>\n\n\n\n Avoid foods prepared with tap water.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n To decrease the risk for acquiring viral hepatitis, clients should prepare foods with<\/p>\n\n\n\n purified water.<\/p>\n\n\n\n 48\u2026A nurse is providing teaching to a client about the manifestations of uterine<\/p>\n\n\n\n prolapse. Which of the following statements by the client should indicate to the<\/p>\n\n\n\n nurse a need for further teaching?<\/p>\n\n\n\n Feces can be present in the vagina.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The presence of feces in the vagina is a manifestation of a genital fistula. This<\/p>\n\n\n\n statement indicates a need for further teaching.<\/p>\n\n\n\n 49\u2026A nurse is assessing a client who has had staples removed from an abdominal<\/p>\n\n\n\n wound postoperatively. The nurse notes separation of the wound edges with<\/p>\n\n\n\n copious light-brown serous drainage. Which of the following actions should the<\/p>\n\n\n\n nurse perform first?<\/p>\n\n\n\n Cover the wound with a moist, sterile gauze dressing.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n The client’s wound has dehisced, or opened along the suture line, and is now<\/p>\n\n\n\n draining. The primary clinical objective in managing a dehisced wound is to keep<\/p>\n\n\n\n it clean and moist, and manage any exudate. The nurse’s priority action therefore<\/p>\n\n\n\n is to cover the wound with a moist, sterile, saline-soaked gauze dressing<\/p>\n\n\n\n 50\u2026A nurse is assessing a client’s wound dressing, and observes a watery red<\/p>\n\n\n\n drainage. The nurse should document this drainage as which of the<\/p>\n\n\n\n following? Serosanguineous<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Watery red drainage should be documented as serosanguineous.<\/p>\n\n\n\n 51\u2026A nurse is providing instructions for a 52-year-old client who is scheduled for a<\/p>\n\n\n\n colonoscopy. The client reports that he has not had the procedure before and is<\/p>\n\n\n\n very anxious about feeling pain during the procedure. Which of the following<\/p>\n\n\n\n responses by the nurse is appropriate?<\/p>\n\n\n\n Before the examination, your provider will give you a sedative that will make<\/p>\n\n\n\n you sleepy.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n This therapeutic response appropriately addresses the client’s concerns. The<\/p>\n\n\n\n client is seeking information and this response provides the client with accurate<\/p>\n\n\n\n information. It can also lead to further discussion about the procedure.<\/p>\n\n\n\n 52\u2026A nurse is teaching a client about preventing osteoporosis. Which of the<\/p>\n\n\n\n following statements by the client indicates a need for further teaching?<\/p>\n\n\n\n I will reduce my intake of vitamin K-rich foods.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Vitamin K is necessary for bone health. The nurse should instruct the client to<\/p>\n\n\n\n increase her intake of vitamin K-rich foods\u2014such as green, leafy vegetables\u2014to<\/p>\n\n\n\n promote bone health<\/p>\n\n\n\n 53\u2026A nurse is selecting a qualified staff member to double check a blood label<\/p>\n\n\n\n with a client ID bracelet prior to infusing a unit of blood. The nurse should<\/p>\n\n\n\n identify that which of the following persons is qualified?<\/p>\n\n\n\n Oncology nurse<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse should ask another nurse or a provider to double check the blood label<\/p>\n\n\n\n and client ID prior to an infusion.<\/p>\n\n\n\n 54\u2026A nurse is caring for a client who is scheduled to have a magnetic resonance<\/p>\n\n\n\n imaging (MRI) scan. The client asks the nurse what to expect during the<\/p>\n\n\n\n procedure. Which of the following statements should the nurse make?<\/p>\n\n\n\n An MRI scan is very noisy, and you will be allowed to wear earplugs while in the<\/p>\n\n\n\n scanner.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse should instruct the client that many clients report being disconcerted<\/p>\n\n\n\n by the loud thumping and humming noises produced by the scanner, and for that<\/p>\n\n\n\n reason, earplugs are offered to reduce the discomfort<\/p>\n\n\n\n 55\u2026A nurse is planning care for a client who has end-stage cirrhosis of the liver<\/p>\n\n\n\n with encephalopathy. Which of the following interventions should the nurse plan<\/p>\n\n\n\n to implement to decrease the client’s ammonia level?<\/p>\n\n\n\n Reduce the client’s intake of protein.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Ammonia is formed in the gastrointestinal tract by the action of bacteria on<\/p>\n\n\n\n protein. Limiting dietary protein intake can assist with decreasing the<\/p>\n\n\n\n client’s ammonialevel. Protein is necessary for healing, so strict limitation<\/p>\n\n\n\n of dietary protein is not recommended.<\/p>\n\n\n\n 56\u2026A nurse is caring for a client who is unconscious and has a breathing pattern<\/p>\n\n\n\n characterized by alternating periods of hyperventilation and apnea. The nurse<\/p>\n\n\n\n should document that the client has which of the following respiratory<\/p>\n\n\n\n alterations?<\/p>\n\n\n\n Cheyne-Stokes respirations<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Cheyne-Stokes respirations (CSR) are characterized by a rhythmic increase (to the<\/p>\n\n\n\n point of hyperventilation) and decrease (to the point of apnea) in the rate and<\/p>\n\n\n\n depth of respiration. CSR are common respiratory alterations seen in clients who<\/p>\n\n\n\n are unconscious, comatose, or moribund (approaching death).<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n 57\u2026A nurse is caring for a client scheduled to receive external radiation to the<\/p>\n\n\n\n neck for cancer of the larynx. During a pre-treatment exam, the nurse explains<\/p>\n\n\n\n to the client that the most likely side effect would be<\/p>\n\n\n\n Dysphagia.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Radiation therapy does not hurt while it is being given. But the side effects that<\/p>\n\n\n\n people may get from radiation therapy can cause pain or discomfort. Only the<\/p>\n\n\n\n area of treatment is affected by the radiation, so dysphagia (trouble swallowing)<\/p>\n\n\n\n would be an expected side effect. Other possible side effects include<\/p>\n\n\n\n hoarseness, xerostomia (dry mouth), loss of taste, and skin redness<\/p>\n\n\n\n 58\u2026A nurse is caring for a client who is 1-day postoperative following a left lower<\/p>\n\n\n\n lobectomy and has a chest tube in place. When assessing the client’s three-<\/p>\n\n\n\n chamber drainage system, the nurse notes that there is no bubbling in the<\/p>\n\n\n\n suction control chamber. Which of the following actions should the nurse take?<\/p>\n\n\n\n Verify that the suction regulator is on and check the tubing for leaks.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n A lack of bubbling may indicate that either the suction regulator is turned off or<\/p>\n\n\n\n that there is a leak in the tubing.<\/p>\n\n\n\n 59\u2026A nurse is caring for a client who has a severe gangrenous infection of the<\/p>\n\n\n\n right lower extremity. The nurse should plan preoperative teaching based on the<\/p>\n\n\n\n possibility of which of the following amputation procedures?<\/p>\n\n\n\n Your pain will gradually become less severe.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Phantom leg pain usually diminishes over time, and often is intermittent in<\/p>\n\n\n\n response to a trigger.<\/p>\n\n\n\n 60\u2026A female middle adult client tells a nurse that she tested positive for a<\/p>\n\n\n\n mutant BRCA1 gene. The nurse should recognize that the client is at an increased<\/p>\n\n\n\n risk for which of the following situations?<\/p>\n\n\n\n Developing breast cancer<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The BRCA1 gene is used to determine the probability of a client developing breast<\/p>\n\n\n\n cancer. BRCA1 genetic testing is used for women who have a strong family history<\/p>\n\n\n\n of breast cancer<\/p>\n\n\n\n 61\u2026A nurse is planning a teaching session about hysterosalpingography for a<\/p>\n\n\n\n client who has a diagnosis of infertility. The nurse should include which of the<\/p>\n\n\n\n following information in the teaching plan?<\/p>\n\n\n\n The client might experience shoulder pain following the procedure.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Shoulder pain can occur due to phrenic nerve irritation cause by the contrast<\/p>\n\n\n\n media.<\/p>\n\n\n\n 62\u2026A nurse is caring for a client who is experiencing menopausal symptoms and<\/p>\n\n\n\n asks the nurse about menopausal hormone therapy (HT). The nurse should inform<\/p>\n\n\n\n the client that HT is not recommended due to which of the following findings in<\/p>\n\n\n\n the client’s medical history?<\/p>\n\n\n\n History of breast cancer<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Women with a history of breast cancer should be counseled against using HT.<\/p>\n\n\n\n 63\u2026A nurse is planning care for a client who has immunosuppression following<\/p>\n\n\n\n chemotherapy.Which of the following interventions should the nurse include<\/p>\n\n\n\n in the plan of care?<\/p>\n\n\n\n Limit the number of health care workers entering the room.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse should limit the number of health care workers entering the client’s<\/p>\n\n\n\n room to prevent possible overexposure to microorganisms that can lead to an<\/p>\n\n\n\n infection.<\/p>\n\n\n\n 64\u2026A nurse is preparing a client who has AIDS for discharge. Which of the<\/p>\n\n\n\n following statements should the nurse include in the discharge instructions?<\/p>\n\n\n\n Prevent the spread of infection with good household cleaning practices.<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The client should follow standard precautions and use a 1:10 solution of bleach to<\/p>\n\n\n\n disinfect areas that come into contact with blood and body fluids.<\/p>\n\n\n\n 65\u2026A nurse is caring for four hospitalized clients. Which of the following clients<\/p>\n\n\n\n should the nurse identify as being at risk for fluid volume deficit?<\/p>\n\n\n\n The client who has gastroenteritis and is febrile.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n This client has two risk factors for the development of fluid volume deficit, or<\/p>\n\n\n\n dehydration. Gastroenteritis is characterized by diarrhea and may also be<\/p>\n\n\n\n associated with vomiting, so it can be a significant source of fluid loss. The client<\/p>\n\n\n\n who has a fever can also lose fluid via diaphoresis, and fever raises the metabolic<\/p>\n\n\n\n rate, further putting the client at increased risk for dehydration. Consequently, this<\/p>\n\n\n\n is the client at greatest risk for fluid volume deficit.<\/p>\n\n\n\n 66\u2026A nurse is caring for a client with a tracheostomy. The client’s partner has<\/p>\n\n\n\n been taught to perform suctioning. Which of the following actions by the partner<\/p>\n\n\n\n should indicate to the nurse a readiness for the client’s discharge?<\/p>\n\n\n\n Performing the procedure independently<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse should recognize that the client is ready for discharge when the spouse<\/p>\n\n\n\n demonstrates an ability to perform the procedure that will need to be performed<\/p>\n\n\n\n independently at home<\/p>\n\n\n\n 67\u2026A nurse is caring for a client who is receiving cisplatin to treat bladder cancer.<\/p>\n\n\n\n After several treatments, the client reports fatigue. Which of the following actions<\/p>\n\n\n\n should the nurse take?<\/p>\n\n\n\n Check the results of the client’s most recent CBC<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The client might have anemia as a result of myelosuppression (bone marrow<\/p>\n\n\n\n suppression) from the chemotherapy. If so, she might require treatment for the<\/p>\n\n\n\n anemia (transfusion, medication) and the provider might have to delay further<\/p>\n\n\n\n chemotherapy until her blood counts are higher.<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n 68\u2026A nurse is teaching a client who has septic shock about the development of<\/p>\n\n\n\n disseminated intravascular coagulation (DIC). Which of the following statements<\/p>\n\n\n\n should the nurse make?<\/p>\n\n\n\n DIC is caused by abnormal coagulation involving fibrinogen.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n DIC is caused by abnormal coagulation involving the formation of multiple small<\/p>\n\n\n\n clots that consume clotting factors and fibrinogen faster than the body can<\/p>\n\n\n\n produce them, increasing the risk for hemorrhage.<\/p>\n\n\n\n 69\u2026A nurse is caring for a client who is HIV positive and is one day postoperative<\/p>\n\n\n\n following an appendectomy. The nurse should wear a gown as personal<\/p>\n\n\n\n protective equipment when taking which of the following actions?<\/p>\n\n\n\n Completing a dressing change<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Standard precautions require personal protective equipment when there is a risk<\/p>\n\n\n\n of contact with body fluids. A dressing change does present a risk for coming<\/p>\n\n\n\n into contact with body fluids<\/p>\n\n\n\n 70\u2026A nurse in a clinic is teaching information about cervical polyps with a<\/p>\n\n\n\n client who has a new diagnosis. Which of the following information should the<\/p>\n\n\n\n nurse include in the teaching?<\/p>\n\n\n\n Postcoital bleeding may occur.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The client may experience postcoital bleeding, because the polyps are soft, fragile,<\/p>\n\n\n\n and bleed when touched.<\/p>\n\n\n\n 71\u2026A nurse is planning a presentation about HIV for a church-based group.<\/p>\n\n\n\n Which of the following information about HIV transmission should the nurse<\/p>\n\n\n\n include?<\/p>\n\n\n\n It is primarily transmitted through direct contact with infected body fluids.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse should include in the teaching that HIV is transmitted through direct<\/p>\n\n\n\n contact with infected blood, seminal fluid, vaginal secretions, amniotic fluid,<\/p>\n\n\n\n breast milk and other body fluids<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n 72\u2026A nurse is preparing a client for a radiation treatment who is postoperative<\/p>\n\n\n\n following a mastectomy. The nurse should inform the client to expect which of the<\/p>\n\n\n\n following adverse effects from the treatment?<\/p>\n\n\n\n Fatigue<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse should inform the client to expect fatigue with her radiation treatment.<\/p>\n\n\n\n Fatigue occurs regardless of the radiation target site.<\/p>\n\n\n\n 73\u2026A nurse is caring for a client who has had a spinal cord injury at the level of<\/p>\n\n\n\n the T2-T3 vertebrae. When planning care, the nurse should anticipate which of<\/p>\n\n\n\n the following types of disability?<\/p>\n\n\n\n Paraplegia<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Paraplegia, or paralysis of both legs, is seen after a spinal cord injury below T1.<\/p>\n\n\n\n 74\u2026A nurse is caring for a client who recently had surgery for insertion of a<\/p>\n\n\n\n permanent pacemaker. Which of the following prescriptions should the nurse<\/p>\n\n\n\n clarify?<\/p>\n\n\n\n MRI of the chest<\/p>\n\n\n\n Rational<\/p>\n\n\n\n A permanent pacemaker is a contraindication for MRI of the chest. The magnets in<\/p>\n\n\n\n the machine can create electromagnetic interference and cause the pacemaker to<\/p>\n\n\n\n malfunction.<\/p>\n\n\n\n 75\u2026 A nurse is reviewing laboratory values for a client who has systemic lupus<\/p>\n\n\n\n erythematous (SLE). Which of the following values should give the nurse the best<\/p>\n\n\n\n indication of the client’s renal function?<\/p>\n\n\n\n Serum creatinine<\/p>\n\n\n\n Rational<\/p>\n\n\n\n A renal function disorder reduces the excretion of creatinine, resulting in<\/p>\n\n\n\n increased levels of blood creatinine. Creatinine is a specific and sensitive indicator<\/p>\n\n\n\n of renal function.<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n 76\u2026A nurse is teaching a client about risk factors for osteoarthritis. Which of the<\/p>\n\n\n\n following factors should the nurse include in the teaching? (Select all that apply.)<\/p>\n\n\n\n Incorrect. Bacteria<\/p>\n\n\n\n Incorrect. Diuretics<\/p>\n\n\n\n Aging<\/p>\n\n\n\n Obesity<\/p>\n\n\n\n Smoking<\/p>\n\n\n\n Bacteria is incorrect. Bacterial infections can lead to infectious arthritis, which<\/p>\n\n\n\n does not cause irreversible damage to joints. Infection is not a risk factor for<\/p>\n\n\n\n osteoarthritis.<\/p>\n\n\n\n Diuretics is incorrect. Diuretic therapy is a possible risk factor for gout, but not for<\/p>\n\n\n\n osteoarthritis.<\/p>\n\n\n\n Aging is correct. Aging is a risk factor for osteoarthritis, as the joints bear the load<\/p>\n\n\n\n of the body’s weight over time.<\/p>\n\n\n\n Obesity is correct. Obesity is a risk factor for osteoarthritis, as it increases the load<\/p>\n\n\n\n of the body’s weight over time.<\/p>\n\n\n\n Smoking is correct. Smoking is a risk factor for osteoarthritis, as smoking<\/p>\n\n\n\n predisposes people to the loss of cartilage in the knees.<\/p>\n\n\n\n 77\u2026 A nurse is admitting a client who has acute pancreatitis. Which of the<\/p>\n\n\n\n following provider prescriptions should the nurse anticipate?<\/p>\n\n\n\n Pantoprazole 80 mg IV bolus twice daily<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse should anticipate a provider’s prescription for a proton pump inhibitor<\/p>\n\n\n\n to decrease gastric acid production, which ultimately decrease pancreatic<\/p>\n\n\n\n secretions<\/p>\n\n\n\n 78\u2026 A nurse is caring for a client who is 2 hr postoperative following a<\/p>\n\n\n\n transurethral resection of the prostate (TURP) gland. Which of the following<\/p>\n\n\n\n assessments should the nurse view to be an indication of a postoperative<\/p>\n\n\n\n complication?<\/p>\n\n\n\n Output of burgundy colored<\/p>\n\n\n\n urine Rational<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n Output of burgundy colored urine may indicate venous bleeding, a potential<\/p>\n\n\n\n complication following a TURP. Should this occur, the nurse should inform the<\/p>\n\n\n\n provider and anticipate an order for increased CBI rate or manual irrigation of the<\/p>\n\n\n\n catheter.<\/p>\n\n\n\n 79\u2026A nurse is reviewing the arterial blood gas values of a client who has chronic<\/p>\n\n\n\n kidney disease. Which of the following sets of values should the nurse expect?<\/p>\n\n\n\n pH 7.25, HCO3- 19 mEq\/L, PaCO2 30 mm Hg<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse should expect a client who has renal failure to have metabolic acidosis,<\/p>\n\n\n\n which is characterized by a low HCO3-, a low pH, and a low or normal PaCO2.<\/p>\n\n\n\n Expected reference ranges for these laboratory values are as follows: pH 7.35 to<\/p>\n\n\n\n 7.45, HCO3- 21 to 28 mEq\/L, and PaCO2 35 to 45 mm Hg.<\/p>\n\n\n\n 80\u2026A nurse is caring for a client who was admitted with bleeding esophageal<\/p>\n\n\n\n varices and has an esophagogastric balloon tamponade with a Sengstaken-<\/p>\n\n\n\n Blakemore tube to control the bleeding. Which of the following actions should the<\/p>\n\n\n\n nurse take?<\/p>\n\n\n\n Provide frequent oral and nares care.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n A client who has a Sengstaken-Blakemore tube in place is unable to swallow. If<\/p>\n\n\n\n the client is alert, the nurse should encourage the client to spit saliva into a tissue<\/p>\n\n\n\n or basin. If the client is not alert, gentle suctioning of the oral cavity and nares<\/p>\n\n\n\n might be required to remove secretions.<\/p>\n\n\n\n 81\u2026A nurse is providing teaching to a client who is postoperative following<\/p>\n\n\n\n coronary artery bypass graft (CABG) surgery and is receiving opioid medications<\/p>\n\n\n\n to manage discomfort. Aside from managing pain, which of the following desired<\/p>\n\n\n\n effects of medications should the nurse identify as most important for the client’s<\/p>\n\n\n\n recovery?<\/p>\n\n\n\n It facilitates the client’s deep breathing<\/p>\n\n\n\n 82\u2026 A nurse is presenting a community-based program about HIV and AIDS. A<\/p>\n\n\n\n client asks the nurse to describe the initial symptoms experienced with HIV<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n infection. Which of the following manifestations should the nurse include in the<\/p>\n\n\n\n explanation of initial symptoms?<\/p>\n\n\n\n Flu-like symptoms and night sweats<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse should explain that the initial symptoms may include flu-like symptoms<\/p>\n\n\n\n and night sweats in category A of HIV infection.<\/p>\n\n\n\n 83\u2026 A nurse is implementing a plan of care for a client who has AIDS with<\/p>\n\n\n\n recurring pneumonia. Which of the following actions should the nurse take?<\/p>\n\n\n\n Obtain a sputum culture<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse should obtain a sputum culture to determine which antibiotic is needed<\/p>\n\n\n\n for the organism that is causing the pneumonia<\/p>\n\n\n\n 84\u2026A nurse is caring for a client who reports a new onset of severe chest pain.<\/p>\n\n\n\n Which of the following actions should the nurse take to determine if the client is<\/p>\n\n\n\n experiencing a myocardial infarction?<\/p>\n\n\n\n Perform a 12-lead ECG<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse should perform a 12-lead ECG when a client complains of chest pain to<\/p>\n\n\n\n determine if the client is experiencing a myocardial infarction.<\/p>\n\n\n\n 85\u2026 A nurse is caring for a client who has advanced lung cancer. The client’s<\/p>\n\n\n\n provider has recommended hospice services for the client. Which of the following<\/p>\n\n\n\n statements by the client indicates a correct understanding of hospice care?<\/p>\n\n\n\n I should expect the hospice team to help me manage my dyspnea.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Dyspnea is a manifestation of terminal lung cancer. The primary purpose of<\/p>\n\n\n\n hospice care is to provide relief of symptoms related to a terminal illness.<\/p>\n\n\n\n 86\u2026A nurse is establishing health promotion goals for a female client who<\/p>\n\n\n\n smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following<\/p>\n\n\n\n goals should the nurse include?<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n The client will walk for 30 min 5 days a week.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n CDC recommendations include engaging in a moderate exercise, such as<\/p>\n\n\n\n walking, for a total of 150 min each week.<\/p>\n\n\n\n 87\u2026A nurse is caring for a client who develops a ventricular fibrillation rhythm.<\/p>\n\n\n\n The client is unresponsive, pulseless, and apneic. Which of the following actions<\/p>\n\n\n\n is the nurse’s priority?<\/p>\n\n\n\n Defibrillation<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The greatest risk to the client is death from a lack of cardiac output. Ventricular<\/p>\n\n\n\n fibrillation is a lethal rhythm in which the ventricles are in a quivering pattern and<\/p>\n\n\n\n there is no atrial activity. Defibrillation is essential to resolve ventricular<\/p>\n\n\n\n fibrillation promptly and convert the rhythm to restore cardiac output. The nurse<\/p>\n\n\n\n should follow defibrillation with cardiopulmonary resuscitation and repeated<\/p>\n\n\n\n defibrillation, if necessary, to convert the ventricular fibrillation into a sustainable<\/p>\n\n\n\n rhythm.<\/p>\n\n\n\n 88\u2026A nurse in a cardiac care unit is caring for a client with acute right-sided heart<\/p>\n\n\n\n failure. Which of the following findings should the nurse expect?<\/p>\n\n\n\n Elevated central venous pressure (CVP).<\/p>\n\n\n\n Rational<\/p>\n\n\n\n CVP is a measurement of the pressure in the right atria or ventricle at the end of<\/p>\n\n\n\n diastole. An elevated CVP is indicative of heart failure<\/p>\n\n\n\n 89\u2026A nurse is reviewing the arterial blood gas (ABG) results of a client who the<\/p>\n\n\n\n provider suspects has metabolic acidosis. Which of the following results should<\/p>\n\n\n\n the nurse expect to see?<\/p>\n\n\n\n pH below 7.35<\/p>\n\n\n\n Rational<\/p>\n\n\n\n With acidosis, the pH is below 7.35. However, the pH alone does not indicate<\/p>\n\n\n\n whether the problem is metabolic or respiratory. A pH above 7.45 indicates<\/p>\n\n\n\n alkalosis.<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n 90\u2026A nurse is teaching a client who has hypertension and a new prescription for<\/p>\n\n\n\n atenolol. Which of the following findings should the nurse include as adverse<\/p>\n\n\n\n effects of this medication?<\/p>\n\n\n\n Bradycardia<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Atenolol is a beta-blocker, which slows the heart rate. The nurse should instruct<\/p>\n\n\n\n the client to monitor his pulse rate and report bradycardia.<\/p>\n\n\n\n 91\u2026While assessing a client who is receiving continuous IV therapy via his left<\/p>\n\n\n\n forearm, a nurse notes that the site is red, swollen, and painful and that the<\/p>\n\n\n\n surrounding tissues are hard. Which of the following actions should the nurse take<\/p>\n\n\n\n first?<\/p>\n\n\n\n Discontinue the existing IV line<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The greatest risk to the client is injury from the IV infiltration damaging soft<\/p>\n\n\n\n tissues surrounding the catheter. Therefore, the first action the nurse should take<\/p>\n\n\n\n is to discontinue the existing IV line.<\/p>\n\n\n\n 92\u2026A nurse in an emergency department is caring for a client who reports<\/p>\n\n\n\n substernal chest pain and dyspnea. The client is vomiting and is diaphoretic.<\/p>\n\n\n\n Which of the following laboratory tests are used to diagnose a myocardial<\/p>\n\n\n\n infarction? (Select all that apply.)<\/p>\n\n\n\n Troponin I<\/p>\n\n\n\n Troponin T<\/p>\n\n\n\n Incorrect. Plasma low-density lipoproteins<\/p>\n\n\n\n CPK<\/p>\n\n\n\n Myoglobin<\/p>\n\n\n\n 93\u2026A nurse is caring for a client who has a chest tube connected to a closed<\/p>\n\n\n\n drainage system and needs to be transported to the x-ray department. Which of<\/p>\n\n\n\n the following actions should the nurse take?<\/p>\n\n\n\n Keep the drainage system below the level of the client’s chest at all times.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n During transport, the drainage system should be kept below the level of the<\/p>\n\n\n\n client’s chest to prevent air and drainage fluid from re-entering the thoracic<\/p>\n\n\n\n cavity<\/p>\n\n\n\n 94\u2026A nurse is caring for a client who has a three-chamber closed chest tube<\/p>\n\n\n\n system. Which of the following actions should the nurse take after noticing a rise<\/p>\n\n\n\n in the water seal chamber with client inspiration?<\/p>\n\n\n\n Continue to monitor the client.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The fluid in the water seal chamber rises 2 to 4 inches during inhalation and falls<\/p>\n\n\n\n during exhalation. This is a process called tidaling. An absence of tidaling might<\/p>\n\n\n\n indicate a fully expanded lung or an obstruction in the chest tube.<\/p>\n\n\n\n 95\u2026A nurse is assessing a client’s wound dressing, and observes a watery red<\/p>\n\n\n\n drainage. The nurse should document this drainage as which of the<\/p>\n\n\n\n following? Serosanguineous<\/p>\n\n\n\n 96\u2026A nurse is teaching a client about snacks that are appropriate on a low-fat,<\/p>\n\n\n\n low-sodium, and low-colesterol diet. Which of the following food choices by<\/p>\n\n\n\n the client indicates the need for further teaching?<\/p>\n\n\n\n A slice of cheese<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The client should limit the intake of cheese due to high levels of fat and sodium.<\/p>\n\n\n\n 97\u2026A nurse is admitting a client who has a serum calcium level of 12.3 mg\/dL and<\/p>\n\n\n\n initiates cardiac monitoring. Which of the following findings should the nurse<\/p>\n\n\n\n expect during the initial assessment?<\/p>\n\n\n\n Lethargy<\/p>\n\n\n\n Rational<\/p>\n\n\n\n A serum calcium level of 12.3 mg\/dL is above the expected reference range. The<\/p>\n\n\n\n nurse should monitor the client for lethargy, generalized weakness, and confusion.<\/p>\n\n\n\n 98\u2026A nurse is preparing to initiate a transfusion of packed RBC for a client<\/p>\n\n\n\n who has anemia. Which of the following actions should the plan to nurse<\/p>\n\n\n\n take?<\/p>\n\n\n\n Check the client’s vital signs every hour during the transfusion.<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse should check the client’s vital signs every 15 min at the start of the<\/p>\n\n\n\n transfusion, then every 1 hr to monitor for a transfusion reaction.<\/p>\n\n\n\n 99\u2026A nurse is planning to teach a client about a lowpotassium diet. Which of the<\/p>\n\n\n\n following foods should the nurse instruct the client to avoid? (Select all that<\/p>\n\n\n\n apply.)<\/p>\n\n\n\n Incorrect. Butter<\/p>\n\n\n\n Incorrect. Poultry<\/p>\n\n\n\n Correct. Yogurt<\/p>\n\n\n\n Incorrect. Frozen vegetables<\/p>\n\n\n\n Correct. Orange juice<\/p>\n\n\n\n 100..A nurse is reviewing the laboratory results of a client who has a pressure<\/p>\n\n\n\n ulcer. The nurse should identify an elevation in which of the following laboratory<\/p>\n\n\n\n values as an indication that the client has developed an infection?<\/p>\n\n\n\n WBC count<\/p>\n\n\n\n Rational<\/p>\n\n\n\n An elevation in the WBC count (leukocytosis) indicates that the client\u2019s immune<\/p>\n\n\n\n system is defending him against the pathogens causing an infection.<\/p>\n\n\n\n 101..A nurse is caring for a client who has a cardiopulmonary arrest. The nurse<\/p>\n\n\n\n anticipates the emergency response team will administer which of the following<\/p>\n\n\n\n medications if the client’s restored rhythm is symptomatic bradycardia?<\/p>\n\n\n\n Atropine<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The team administers atropine during CPR if the client has symptomatic<\/p>\n\n\n\n bradycardia, or is hemodynamically unstable.<\/p>\n\n\n\n Epinephrine<\/p>\n\n\n\n The team administers epinephrine during cardiopulmonary resuscitation (CPR) to<\/p>\n\n\n\n clients who have asystole or pulseless electrical activity.<\/p>\n\n\n\n Magnesium<\/p>\n\n\n\n The team administers magnesium during CPR for clients who have torsade de<\/p>\n\n\n\n pointes, which is a specific type of ventricular tachycardia.<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n Sodium bicarbonate<\/p>\n\n\n\n The team administers sodium bicarbonate to correct metabolic acidosis that does<\/p>\n\n\n\n not improve with CPR.<\/p>\n\n\n\n 102..A nurse is developing a plan of care for a client who is postoperative. Which<\/p>\n\n\n\n of the following interventions should the nurse include in the plan to prevent<\/p>\n\n\n\n pulmonary complications?<\/p>\n\n\n\n Encourage the use of an incentive spirometer<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Incentive spirometry expands the lungs and promotes gas exchange after surgery<\/p>\n\n\n\n which can help prevent pulmonary complications.<\/p>\n\n\n\n 103..A nurse is planning care for a client who is being treated with<\/p>\n\n\n\n chemotherapy and radiation for metastatic breast cancer, and who has<\/p>\n\n\n\n neutropenia.Thenurseshould include which of the following restrictions in the<\/p>\n\n\n\n client’s plan of care?<\/p>\n\n\n\n Fresh flowers and potted plants in the room<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Clients who are receiving chemotherapy and radiation therapy are likely to<\/p>\n\n\n\n become immunocompromised as a result of neutropenia, a decreased white<\/p>\n\n\n\n blood cell (WBC) count. Because micro-organisms are likely to be present on fresh<\/p>\n\n\n\n flowers and plants, immunocompromised clients are instructed not to accept<\/p>\n\n\n\n such gifts into the room. In addition, the client is instructed to eat only thoroughly<\/p>\n\n\n\n cooked meats and thoroughly washed fruits and vegetables.<\/p>\n\n\n\n Immunocompromised clients are more susceptible to infection and illness<\/p>\n\n\n\n from food-borne bacteria than other clients.<\/p>\n\n\n\n 104..A nurse is caring for a client who has heart failure and a new prescription for<\/p>\n\n\n\n furosemide. For which of the following adverse effects should the nurse monitor?<\/p>\n\n\n\n Hypokalemia<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Hypokalemia is an adverse effect of furosemide<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n 105..A nurse is caring for a client who has a postoperative ileus and an NG tube<\/p>\n\n\n\n that has drained 2,500 mL in the past 6 hr. Which of the following electrolyte<\/p>\n\n\n\n imbalances should the nurse monitor the client for?<\/p>\n\n\n\n Decreased potassium level<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Hypokalemia is an electrolyte imbalance in which the serum potassium level is<\/p>\n\n\n\n less than 3.5 mEq\/L. Hypokalemia may be the result of diuretic use, diarrhea,<\/p>\n\n\n\n vomiting, and prolonged nasogastric suctioning<\/p>\n\n\n\n 106.. A nurse is caring for a client who has hypertension and develops epistaxis.<\/p>\n\n\n\n Which of the following actions should the nurse take? (Select all that apply.)<\/p>\n\n\n\n Apply pressure to the nares.<\/p>\n\n\n\n Place ice to the bridge of the client’s nose.<\/p>\n\n\n\n Incorrect. Instruct the client to blow his<\/p>\n\n\n\n nose. Incorrect. Tilt the client’s head<\/p>\n\n\n\n backward Move the client into high-Fowler’s<\/p>\n\n\n\n position.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Apply pressure to the nares is correct. Applying direct pressure to the lateral<\/p>\n\n\n\n aspects of the nose helps to clot the blood. The nurse should apply firm and<\/p>\n\n\n\n consistent pressure for several minutes until coagulation occurs.<\/p>\n\n\n\n Place ice to the bridge of the client’s nose is correct. Placing an ice pack on the<\/p>\n\n\n\n nose causes the blood vessels to vasoconstrict, which decreases bleeding. The<\/p>\n\n\n\n nurse should use a barrier, such as a wash cloth, to avoid skin damage from the<\/p>\n\n\n\n direct application of ice to the skin. Ice packs should not be left on the skin for<\/p>\n\n\n\n longer than 20 min.<\/p>\n\n\n\n Instruct the client to blow his nose is incorrect. The nurse should instruct the<\/p>\n\n\n\n client to avoid blowing his nose for 24 hr as this can cause dislodgement of clots.<\/p>\n\n\n\n The nurse should also discourage coughing, straining, or sneezing as these<\/p>\n\n\n\n activities can also cause the blood vessels to weaken, which can trigger<\/p>\n\n\n\n rebleeding.<\/p>\n\n\n\n Tilt the client’s head backward is incorrect. The nurse should tilt the client’s body<\/p>\n\n\n\n and head forward to decrease the risk for aspiration and swallowing of blood.<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n Move the client into high-Fowler’s position is correct. Sitting upright facilitates<\/p>\n\n\n\n breathing and decreases the risk for aspiration.<\/p>\n\n\n\n 107..A nurse is reviewing the laboratory values of a client who had a myocardial<\/p>\n\n\n\n infarction 3 hr ago. The nurse should expect which of the following laboratory<\/p>\n\n\n\n values to be elevated?<\/p>\n\n\n\n Troponin I<\/p>\n\n\n\n 108..A nurse is performing an ECG on a client who is experiencing chest pain.<\/p>\n\n\n\n Which of the following statements should the nurse make?<\/p>\n\n\n\n I will need to apply electrodes to your chest and extremities.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse should inform the client that she will apply small electrodes to the<\/p>\n\n\n\n client’s chest and extremities before conducting the test. These electrodes<\/p>\n\n\n\n transmit electrical current and allow for the recording of the heart’s electrical<\/p>\n\n\n\n activity<\/p>\n\n\n\n 109..A nurse is preparing to administer potassium chloride (KCL) to a client who is<\/p>\n\n\n\n receiving diuretic therapy. The nurse reviews the client’s serum potassium level<\/p>\n\n\n\n results and discovers the client’s potassium level is 3.2 mEq\/L. Which of the<\/p>\n\n\n\n following actions should the nurse take?<\/p>\n\n\n\n Give the ordered KCL as prescribed.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The client’s serum potassium level is below the recommended reference range.<\/p>\n\n\n\n The nurse should administer the KCL as prescribed.<\/p>\n\n\n\n 110.. A nurse is completing discharge teaching with a client following arthroscopic<\/p>\n\n\n\n knee surgery. Which of the following instructions should the nurse include in the<\/p>\n\n\n\n teaching?<\/p>\n\n\n\n Apply ice to the affected area.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Arthroscopy is a surgical procedure used to visualize, diagnose and treat problems<\/p>\n\n\n\n inside a joint. Applying ice to the affected area in the immediate postoperative<\/p>\n\n\n\n period (first 24 hr) reduces pain and swelling.<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n 111..A nurse is caring for a client who has pericarditis and reports feeling a new<\/p>\n\n\n\n onset of palpitations and shortness of breath. Which of the following assessments<\/p>\n\n\n\n should indicate to the nurse that the client may have developed atrial fibrillation?<\/p>\n\n\n\n Different apical and radial pulses.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Atrial fibrillation is rapid, disorganized electrical activity of the heart in which the<\/p>\n\n\n\n atrium depolarizes too quickly and sends erratic impulses to the ventricles. The<\/p>\n\n\n\n presence of a pulse deficit between the apical and radial pulses is an indication of<\/p>\n\n\n\n atrial fibrillation. The nurse should assess further by obtaining an ECG or<\/p>\n\n\n\n telemetry reading<\/p>\n\n\n\n 112..A client is planning to perform nasotracheal suction for a client who has<\/p>\n\n\n\n COPD and an artificial airway. Which of the following actions should the<\/p>\n\n\n\n nurse take?<\/p>\n\n\n\n Preoxygenate the client with 100% oxygen for up to 3 min.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n To prevent hypoxemia, the nurse should preoxygenate the client with 100%<\/p>\n\n\n\n oxygen for 30 seconds to 3 min prior to suctioning.<\/p>\n\n\n\n 113..A nurse is caring for a client who has a new diagnosis of essential<\/p>\n\n\n\n hypertension. The nurse should monitor the client for which of the following<\/p>\n\n\n\n findings that is consistent with this diagnosis?<\/p>\n\n\n\n Vertigo<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse should monitor the client for findings such as vertigo, headache, facial<\/p>\n\n\n\n flushing, and fainting. These manifestations are consistent with a new diagnosis<\/p>\n\n\n\n of essential hypertension.<\/p>\n\n\n\n 114..A nurse in an urgent care center is caring for a client who is having an acute<\/p>\n\n\n\n asthma exacerbation. Which of the following actions is the nurse’s highest<\/p>\n\n\n\n priority?<\/p>\n\n\n\n Administering a nebulized beta-adrenergic<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The greatest risk to the client’s safety is airway obstruction. Beta-adrenergic<\/p>\n\n\n\n medications act as bronchodilators. They provide prompt relief of airflow<\/p>\n\n\n\n obstruction by relaxing bronchiolar smooth muscle and are the initial priority<\/p>\n\n\n\n intervention when a client has an acute asthma exacerbation.<\/p>\n\n\n\n 115..The nurse is caring for a client who has heart failure and a history of asthma.<\/p>\n\n\n\n The nurse reviews the provider’s orders and recognizes that clarification is needed<\/p>\n\n\n\n for which of the following medications?<\/p>\n\n\n\n Carvedilol<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Medications that block beta-2 receptors, such as carvedilol, are contraindicated in<\/p>\n\n\n\n clients with asthma.<\/p>\n\n\n\n 116.. A nurse is caring for a client who the provider suspects might have<\/p>\n\n\n\n pernicious anemia. The nurse should expect the provider to prescribe which of<\/p>\n\n\n\n the following diagnostic tests?<\/p>\n\n\n\n Schilling test<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The Schilling test helps determine the cause of vitamin B12 deficiency, which leads<\/p>\n\n\n\n to pernicious anemia.<\/p>\n\n\n\n 117..A nurse is teaching a client who has been taking prednisone to treat<\/p>\n\n\n\n asthma and has a new prescription to discontinue the medication. The nurse<\/p>\n\n\n\n should explain to the client to reduce the dose gradually to prevent which of the<\/p>\n\n\n\n following adverse effects?<\/p>\n\n\n\n Adrenocortical insufficiency<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Prednisone, a corticosteroid, is similar to cortisol, the glucocorticoid hormone<\/p>\n\n\n\n produced by the adrenal glands. It relieves inflammation and is used to treat<\/p>\n\n\n\n certain forms of arthritis, severe allergies, autoimmune disorders, and asthma.<\/p>\n\n\n\n Administration of glucocorticoids can suppress production of glucocorticoids, and<\/p>\n\n\n\n an abrupt withdrawal of the drug can lead to a syndrome of adrenal insufficiency.<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n 118..A nurse is providing teaching for a client who has hypertension and a<\/p>\n\n\n\n prescription change from metoprolol to metoprolol\/hydrochlorothiazide. Which of<\/p>\n\n\n\n the following statements by the client indicates an understanding of the teaching?<\/p>\n\n\n\n With the new medication, I should experience fewer side effects.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The client has stated an understanding of the purpose of the addition of the<\/p>\n\n\n\n hydrochlorothiazide (HCTZ) to the metoprolol dosage. When used in<\/p>\n\n\n\n combination with thiazide diuretics, a lower dose of the beta-blocker can be<\/p>\n\n\n\n used. The benefit is there are fewer side effects when beta-blockers (and other<\/p>\n\n\n\n antihypertensives) are used in lower dosages<\/p>\n\n\n\n 119..A client is teaching a client who has a new prescription for<\/p>\n\n\n\n hydrochlorothiazide for management of hypertension. Which of the following<\/p>\n\n\n\n instructions should the nurse include?<\/p>\n\n\n\n Monitor for leg cramps.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Hydrochlorothiazide can cause hypokalemia. The client should monitor for<\/p>\n\n\n\n manifestations of hypokalemia, such as fatigue, tachycardia, leg cramps, and<\/p>\n\n\n\n muscle weakness.<\/p>\n\n\n\n 120..A nurse is providing teaching to a client who has hypertension and a new<\/p>\n\n\n\n prescription for hydrochlorothiazide. Which of the following instructions should<\/p>\n\n\n\n the nurse provide?<\/p>\n\n\n\n Take the medication early in the day.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse should instruct the client to take hydrochlorothiazide early in the day to<\/p>\n\n\n\n avoid nocturia.<\/p>\n\n\n\n 121..A nurse in a provider’s office is reviewing the laboratory results of a client<\/p>\n\n\n\n who takes furosemide for hypertension. The nurse notes that the client’s<\/p>\n\n\n\n potassium level is 3.3 mEq\/L. The nurse should monitor the client for which of<\/p>\n\n\n\n the following complications?<\/p>\n\n\n\n Cardiac dysrhythmias<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n Rational<\/p>\n\n\n\n This client\u2019s potassium level is below the expected reference range.<\/p>\n\n\n\n Hypokalemia can cause a numberof cardiac effectsincluding flattened Twaves,<\/p>\n\n\n\n prominent U waves, and S-T depression.<\/p>\n\n\n\n 122..A nurse is providing teaching about a heart healthy diet to a group of clients<\/p>\n\n\n\n with hypertension. Which of the following statements by one of the clients<\/p>\n\n\n\n indicates a need for further teaching?<\/p>\n\n\n\n I may eat 10 ounces of lean protein each day<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Lean meats should be limited to 5 to 6 oz per day. This statement by a client<\/p>\n\n\n\n requires additional teaching.<\/p>\n\n\n\n 123..A nurse on a medical-surgical unit is performing an admission assessment of<\/p>\n\n\n\n a client who has COPD with emphysema. The client reports that he has a frequent<\/p>\n\n\n\n productive cough and is short of breath. The nurse should anticipate which of the<\/p>\n\n\n\n following assessment findings for this client?<\/p>\n\n\n\n Increased anteroposterior diameter of the chest<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse should anticipate an increased anteroposterior diameter of the chest<\/p>\n\n\n\n (barrel chest) because of chronic hyperinflation of the lungs<\/p>\n\n\n\n 124..A nurse is evaluating teaching on a client who has a new prescription for<\/p>\n\n\n\n montelukast to treat asthma. Which of the following statements by the client<\/p>\n\n\n\n indicates an understanding of the teaching?<\/p>\n\n\n\n I’ll take this medication once a day in the evening.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Montelukast, a leukotriene modifier, is used to prevent asthma exacerbations. The<\/p>\n\n\n\n client should take it on a daily basis once a day in the evening<\/p>\n\n\n\n 125..A nurse is caring for a client who has asthma and is taking fluticasone. The<\/p>\n\n\n\n nurse should monitor the client for which of the following adverse effects?<\/p>\n\n\n\n Oral candidiasis<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Fluticasone can cause oral candidiasis, or thrush; therefore, the client should rinse<\/p>\n\n\n\n her mouth with water<\/p>\n\n\n\n 126..A nurse is providing discharge teaching to a client who has asthma and new<\/p>\n\n\n\n prescriptions for cromolyn and albuterol, both by nebulizer. Which of the<\/p>\n\n\n\n following statements by the client indicates an understanding of the teaching?<\/p>\n\n\n\n I will be sure to take the albuterol before taking the cromolyn.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The client should always use the bronchodilator (albuterol) prior to using the<\/p>\n\n\n\n leukotriene modifier (cromolyn). Using the bronchodilator first allows the airways<\/p>\n\n\n\n to be opened, ensuring that the maximum dose of medication will get to the<\/p>\n\n\n\n client’s lungs.<\/p>\n\n\n\n 127..A nurse is discharging a child who has sickle cell anemia after an acute crisis<\/p>\n\n\n\n episode. Which of the following instructions should the nurse include in the<\/p>\n\n\n\n teaching?<\/p>\n\n\n\n Offer fluids to your child multiple times every day<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Preventing dehydration is an important step in preventing a sickle cell crisis.<\/p>\n\n\n\n The nurseshouldprovidetheparentswithaspecificfluidgoalforthechildto<\/p>\n\n\n\n reach each day<\/p>\n\n\n\n 128..A nurse is monitoring a client who is receiving a blood transfusion. Which<\/p>\n\n\n\n of the following findings indicates an allergic transfusion reaction?<\/p>\n\n\n\n Generalized urticaria.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse should recognize urticaria asan indicator of anallergic transfusion<\/p>\n\n\n\n reaction. Other clinical manifestations include itching and signs of<\/p>\n\n\n\n anaphylaxis with bronchospasm.<\/p>\n\n\n\n 129..A nurse is collaborating on care for a client who has COPD. Which of<\/p>\n\n\n\n the following tasks should the nurse recommend be referred to an<\/p>\n\n\n\n occupational therapist for assistance?<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n Instructing how to use kitchen tools to prepare a meal<\/p>\n\n\n\n Rational<\/p>\n\n\n\n As a member of the interdisciplinary team, the occupational therapist works with<\/p>\n\n\n\n the client todevelop fine motor skills and coordination, such as improving hand<\/p>\n\n\n\n strength and hand movements. The occupational therapist focuses on self-<\/p>\n\n\n\n management of ADLs, such as skills needed for eating, hygiene, and dressing.<\/p>\n\n\n\n Occupational therapists also can teach clients to perform other independent living<\/p>\n\n\n\n skills, such as cooking and shopping<\/p>\n\n\n\n 130..A nurse is assessing a client for hypoxemia during an asthma attack. Which<\/p>\n\n\n\n of the following manifestations should the nurse expect?<\/p>\n\n\n\n Agitation<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse should expect agitation due to neurological changes from poor oxygen<\/p>\n\n\n\n exchange.<\/p>\n\n\n\n 131.. A nurse is planning to perform a blood transfusion for a client. Which of the<\/p>\n\n\n\n following actions should the nurse plan to take? (Select all that apply.)<\/p>\n\n\n\n Incorrect. Prime the blood tubing with dextrose 5% in water.<\/p>\n\n\n\n Incorrect. Transfuse the blood product within 5 hr after removing it from<\/p>\n\n\n\n refrigeration.<\/p>\n\n\n\n Check the expiration date of the blood product with a second nurse.<\/p>\n\n\n\n 132..A nurse is providing discharge teaching to a client who has asthma and a<\/p>\n\n\n\n new prescriptionforfluticasone\/salmeterol.Forwhichofthefollowingadverse<\/p>\n\n\n\n effects should the nurse instruct the client to report to the provider?<\/p>\n\n\n\n White coating in the mouth<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Fluticasone\/salmeterol is an inhaled glucocorticoid and long acting beta2<\/p>\n\n\n\n adrenergic agonist combination inhalation medication that is used for daily<\/p>\n\n\n\n management of asthma. It is not a rescue medication. An adverse effect of the<\/p>\n\n\n\n medication is oropharyngeal candidiasis. The nurse should instruct the client to<\/p>\n\n\n\n Check vital signs before<\/p>\n\n\n\n transfusion. Insert an IV with a<\/p>\n\n\n\n 19-<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n gargle after each use, use a spacer to reduce the amount of drug in the mouth and<\/p>\n\n\n\n throat, and report any white patches inside the mouth or on the tongue to the<\/p>\n\n\n\n provider<\/p>\n\n\n\n 133\u2026A nurse is monitoring a client who has a chest tube in place connected<\/p>\n\n\n\n to wallsuctionduetoaright-sidedpneumothorax.Theclientcomplainsof<\/p>\n\n\n\n chest burning. Which of the following actions should the nurse take?<\/p>\n\n\n\n Reposition the client.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse repositioning the client is an appropriate action to relieve chest<\/p>\n\n\n\n burning from the chest tube.<\/p>\n\n\n\n 134..A nurse is teaching a middle-age client about hypertension. Which of<\/p>\n\n\n\n the following information should the nurse include in the teaching?<\/p>\n\n\n\n Diuretics are the first type of medication to control hypertension.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse should include in the teaching that diuretic medication is the first type<\/p>\n\n\n\n of medication to control hypertension, by decreasing blood volume and lowering<\/p>\n\n\n\n blood pressure.<\/p>\n\n\n\n 135.. The nurse is caring for a postoperative client who has a chest tube<\/p>\n\n\n\n connected to suction and a water seal drainage system. Which of the following<\/p>\n\n\n\n indicates to the nurse that the chest tube is functioning properly?<\/p>\n\n\n\n Fluctuation of the fluid level within the water seal chamber<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Fluctuation of fluid within the water seal chamber occurs with inspiration and<\/p>\n\n\n\n expiration until the client\u2019s lungs have re-expanded or the system is occluded.<\/p>\n\n\n\n 136.. A nurse is assessing a client who is 1 day postoperative following a<\/p>\n\n\n\n lobectomy and has a chest tube drainage system in place. Which of the<\/p>\n\n\n\n following findings by the nurse indicates a need for intervention?<\/p>\n\n\n\n Development of subcutaneous<\/p>\n\n\n\n emphysema Rational<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n Subcutaneous emphysema is an indication that air is trapped in and under the<\/p>\n\n\n\n skin, which be the result of a pneumothorax and should be reported to the<\/p>\n\n\n\n provider.<\/p>\n\n\n\n 137.. A nurse is caring for a client who had a stroke involving the left cerebral<\/p>\n\n\n\n hemisphere. The nurse should monitor for which of the following findings?<\/p>\n\n\n\n Impaired sense of humor<\/p>\n\n\n\n Rational<\/p>\n\n\n\n A client who had a stroke involving the left cerebral hemisphere is likely to have<\/p>\n\n\n\n language deficits, which include difficult using or comprehending language and<\/p>\n\n\n\n difficulty writing. The nurse should expect a client who had a stroke involving the<\/p>\n\n\n\n right cerebral hemisphere to have an impaired sense of humor.<\/p>\n\n\n\n 138..A nurse is caring for a client who has a T-4 spinal cord injury. Which of the<\/p>\n\n\n\n following client findings should the nurse identify as an indication the client is<\/p>\n\n\n\n at risk for experiencing autonomic dysreflexia?<\/p>\n\n\n\n The client’s bladder becomes distended.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Autonomic dysreflexia (sometimes called hyperreflexia) can occur in clients with<\/p>\n\n\n\n a spinal cord injury at or above the T6 level. Autonomic dysreflexia happens<\/p>\n\n\n\n when there is an irritation, pain, or stimulus to the nervous system below the<\/p>\n\n\n\n level of injury. There are many kinds of stimulation that can precipitate<\/p>\n\n\n\n autonomic dysreflexia. For example, catheter changes, a distended bladder or<\/p>\n\n\n\n bowel, enemas, and sudden position changes. Manifestations include elevated<\/p>\n\n\n\n blood pressure, severe headache, and flushed face.<\/p>\n\n\n\n 139.. A nurse is caring for a client who is receiving cisplatin to treat bladder<\/p>\n\n\n\n cancer. After several treatments, the client reports fatigue. Which of the following<\/p>\n\n\n\n actions should the nurse take?<\/p>\n\n\n\n Check the results of the client’s most recent CBC.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The client might have anemia as a result of myelosuppression (bone marrow<\/p>\n\n\n\n suppression) from the chemotherapy. If so, she might require treatment for the<\/p>\n\n\n\n anemia (transfusion, medication) and the provider might have to delay further<\/p>\n\n\n\n chemotherapy until her blood counts are higher.<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n 140.. A nurse is teaching the family of a client who is receiving treatment for a<\/p>\n\n\n\n spinal cord injury with a halo fixation device. Which of the following statements<\/p>\n\n\n\n should the nurse make?<\/p>\n\n\n\n The purpose of this device is to immobilize the cervical spine.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n A client who has an injury to the cervical spine can have a halo fixation device to<\/p>\n\n\n\n provide immobilization of the head and neck for a period of 8 to 12 weeks.<\/p>\n\n\n\n 141..A nurse is developing a plan of care for a client who has a spinal fracture and<\/p>\n\n\n\n complete spinal cord transection at the level of C5. Which of the following<\/p>\n\n\n\n rehabilitation goals should the nurse add to the client’s plan of care?<\/p>\n\n\n\n Ability to self-feed with the use of adaptive equipment<\/p>\n\n\n\n Rational<\/p>\n\n\n\n A client who has a spinal cord transection at the level of the fifth cervical<\/p>\n\n\n\n vertebrae should have full neck, partial shoulder, back, biceps, and gross elbow<\/p>\n\n\n\n movements. A realistic rehabilitation goal for the client is the ability to feed<\/p>\n\n\n\n himself with the use of adaptive equipment.<\/p>\n\n\n\n 142..A nurse is creating a plan of care for a client who has a history of tonic-clonic<\/p>\n\n\n\n seizure disorder. Which of the following interventions should the nurse include?<\/p>\n\n\n\n (Select all that apply.)<\/p>\n\n\n\n Provide a suction setup at the bedside.<\/p>\n\n\n\n Elevate the side rails near the head when the client is in bed.<\/p>\n\n\n\n Place the bed in the lowest position.<\/p>\n\n\n\n Keep an oxygen setup at the bedside.<\/p>\n\n\n\n Incorrect. Furnish restraints at the bedside.<\/p>\n\n\n\n 143..A nurse is caring for a client who has right-sided acoustic neuroma resulting<\/p>\n\n\n\n in impairment of cranial nerves IX and X. Which of the following actions should<\/p>\n\n\n\n the nurse take?<\/p>\n\n\n\n Place suction equipment at the client’s bedside.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n Cranialnerves IX(glossopharyngeal)andX(vagus)innervatethemuscles ofthe<\/p>\n\n\n\n soft palate, larynx, and pharynx. Impairment of these nerves places the client at<\/p>\n\n\n\n risk foraspiration, making it necessary for the nurse to have access to suction<\/p>\n\n\n\n for the client.<\/p>\n\n\n\n 144..A nurse is caring for a client who has quadriplegia from a spinal cord injury<\/p>\n\n\n\n and reports having a severe headache. The nurse obtains a blood pressure reading<\/p>\n\n\n\n of 210\/108 mm Hg and suspects the client is experiencing autonomic dysreflexia.<\/p>\n\n\n\n Which of the following actions should the nurse take first?<\/p>\n\n\n\n Place the client in a high-Fowler’s position.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The client who is experiencing autonomic dysreflexia is at risk for a<\/p>\n\n\n\n cerebrovascular accident resulting from severe hypertension. According to the<\/p>\n\n\n\n safety and risk reduction priority setting framework, the nurse\u2019s initial action<\/p>\n\n\n\n should be to place the client in a high-Fowler\u2019s position to assist in providing<\/p>\n\n\n\n immediate reduction in blood pressure and intracranial pressure<\/p>\n\n\n\n 145..A nurse is performing a mental status examination (MSE) on a client who has<\/p>\n\n\n\n a new diagnosis of dementia. Which of the following components should the<\/p>\n\n\n\n nurse include? (Select all that apply.)<\/p>\n\n\n\n Grooming<\/p>\n\n\n\n Long-term memory<\/p>\n\n\n\n Incorrect. Support systems<\/p>\n\n\n\n Affect<\/p>\n\n\n\n Incorrect. Presence of pain<\/p>\n\n\n\n 146..A nurse in the emergency room is assessing a client who was brought in<\/p>\n\n\n\n following a seizure. The nurse suspects the client may have meningococcal<\/p>\n\n\n\n meningitis when assessment findings include nuchal rigidity and a petechial rash.<\/p>\n\n\n\n After implementing droplet precautions, which of the following actions should<\/p>\n\n\n\n the nurse initiate next?<\/p>\n\n\n\n Assess the cranial nerves.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The greatest risk to the client is from increased intracranial pressure (ICP)<\/p>\n\n\n\n which may lead to herniation of the brain and death. The nurse should perform<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n neurological assessments including evaluation of the cranial nerves at least every<\/p>\n\n\n\n 4 hr. Early neurological changes to be monitoring for include a decrease in the<\/p>\n\n\n\n level of consciousness, the development of Cushing\u2019s triad (severe hypertension,<\/p>\n\n\n\n widened pulse pressure, and bradycardia), and changes in pupillary reaction<\/p>\n\n\n\n 147..A nurse is receiving a transfer report for a client who has a head injury. The<\/p>\n\n\n\n client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal<\/p>\n\n\n\n response, and 5 for best motor response. Which of the following is an appropriate<\/p>\n\n\n\n conclusion based on this data?<\/p>\n\n\n\n The client opens his eyes when spoken to.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n A GCS of 3-5-5 indicates that the client opens his eyes in response to speech, is<\/p>\n\n\n\n oriented, and is able to localize pain.<\/p>\n\n\n\n The client can follow simple motor commands.<\/p>\n\n\n\n The client’s ability to follow commands would require a score of 6 for best motor<\/p>\n\n\n\n response.<\/p>\n\n\n\n The client is unable to make vocal sound.<\/p>\n\n\n\n The inability of the client to make vocal sounds would result in a score of 1 for<\/p>\n\n\n\n best verbal response.<\/p>\n\n\n\n The client is unconscious.<\/p>\n\n\n\n The unconscious client would have a score of 1 for eye opening and a 1 for best<\/p>\n\n\n\n verbal response.<\/p>\n\n\n\n 148.. A nurse is caring for four hospitalized clients. Which of the following clients<\/p>\n\n\n\n should the nurse identify as being at risk for fluid volume deficit?<\/p>\n\n\n\n The client who has gastroenteritis and is febrile.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n This client has two risk factors for the development of fluid volume deficit, or<\/p>\n\n\n\n dehydration. Gastroenteritis is characterized by diarrhea and may also be<\/p>\n\n\n\n associated with vomiting, so it can be a significant source of fluid loss. The client<\/p>\n\n\n\n who has a fever can also lose fluid via diaphoresis, and fever raises the metabolic<\/p>\n\n\n\n rate, further putting the client at increased risk for dehydration. Consequently, this<\/p>\n\n\n\n is the client at greatest risk for fluid volume deficit.<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n 149..A nurse is performing discharge teaching for a client who has seizures and<\/p>\n\n\n\n a newprescriptionforphenytoin.Whichofthefollowingstatementsbythe<\/p>\n\n\n\n client indicates a need for further teaching?<\/p>\n\n\n\n I’ll be glad when I can stop taking this medicine.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Phenytoin is an anticonvulsant used to treat various types of seizures. Clients on<\/p>\n\n\n\n anticonvulsantmedicationscommonly require them forlifetimeadministration,<\/p>\n\n\n\n and phenytoin should not be stopped without the advice of the client’s provider.<\/p>\n\n\n\n 150.. A nurse is caring for a client who has an intracranial pressure (ICP) reading of<\/p>\n\n\n\n 40 mm Hg. Which assessment should the nurse recognize as a late sign of ICP?<\/p>\n\n\n\n (Select all that apply.)<\/p>\n\n\n\n Confusion<\/p>\n\n\n\n Incorrect. Tachycardia<\/p>\n\n\n\n Incorrect. Hypotension<\/p>\n\n\n\n Nonreactive dilated pupils<\/p>\n\n\n\n Slurred speech<\/p>\n\n\n\n 151..A nurse is assessing a client who has Parkinson’s disease. Which of the<\/p>\n\n\n\n following manifestations should the nurse expect?<\/p>\n\n\n\n Bradykinesia<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse should expect to find bradykinesia or difficulty moving in a client<\/p>\n\n\n\n who has Parkinson’s disease.<\/p>\n\n\n\n 152.. A nurse is teaching a female client who has a new prescription for<\/p>\n\n\n\n transdermal sumatriptan to treat migraine headaches. Which of the following<\/p>\n\n\n\n instructions should the nurse include?<\/p>\n\n\n\n Use contraception while taking this medication.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Sumatriptan can cause teratogenesis and should not be used during pregnancy.<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n 153.. A nurse is presenting discharge instructions to a client who has multiple<\/p>\n\n\n\n sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory<\/p>\n\n\n\n change. Which of the following nursing statements are appropriate?<\/p>\n\n\n\n Implement a schedule to include periods of rest.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse should assist the client in developing a schedule that includes periods<\/p>\n\n\n\n of exercise followed by periods of rest to maintain muscle strength and<\/p>\n\n\n\n coordination.<\/p>\n\n\n\n 154..A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of<\/p>\n\n\n\n the following manifestations should indicate to the nurse the client is experiencing<\/p>\n\n\n\n an increase in intracranial pressure (ICP)? (Select all that apply.)<\/p>\n\n\n\n Headache<\/p>\n\n\n\n Incorrect. Neck pain and stiffness<\/p>\n\n\n\n Slurred speech<\/p>\n\n\n\n Pupillary changes<\/p>\n\n\n\n Disorientation<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Headache is correct. A client who has increasing ICP might manifest a headache.<\/p>\n\n\n\n Neck pain and stiffness is incorrect. Neck pain and stiffness are not<\/p>\n\n\n\n manifestations of increasing ICP.<\/p>\n\n\n\n Slurred speech is correct. A client who has increasing ICP might manifest slurred<\/p>\n\n\n\n speech.<\/p>\n\n\n\n Pupillary changes is correct. A client who has increasing ICP might manifest<\/p>\n\n\n\n pupillary changes.<\/p>\n\n\n\n Disorientation is correct. A client who has increasing ICP might display<\/p>\n\n\n\n disorientation or confusion.<\/p>\n\n\n\n 155.. A nurse in an ICU is assessing a client who has a traumatic brain injury.<\/p>\n\n\n\n Which of the following findings should the nurse identify as a component of<\/p>\n\n\n\n Cushing’s triad?<\/p>\n\n\n\n Bradycardia<\/p>\n\n\n\n Increased ICP from TBI: Cushing’s triad: severe hypertension, bradycardia,<\/p>\n\n\n\n widened pulse pressure<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n 156.. A nurse in an ICU is planning care for a client who is in cariogenic shock. The<\/p>\n\n\n\n nurse should prepare to administer which of the following medications to<\/p>\n\n\n\n increase cardiac output?<\/p>\n\n\n\n Dopamine<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Dopamine increases output by strengthening force of contractions)<\/p>\n\n\n\n 157..A nurse in a provider’s office is assessing a client who has hypertension and<\/p>\n\n\n\n takes propranolol. Which of the following findings should indicate to the nurse<\/p>\n\n\n\n that the client is experiencing an adverse reaction to this medication?<\/p>\n\n\n\n Report of a night cough<\/p>\n\n\n\n 158.. A nurse is assessing a client who has a comminuted fracture of the femur.<\/p>\n\n\n\n Which of the following findings should the nurse identify as an early manifestation<\/p>\n\n\n\n of a fat embolism.<\/p>\n\n\n\n Dyspnea<\/p>\n\n\n\n 159.. A nurse is assessing a client who has a diagnosis of rheumatoid arthritis.<\/p>\n\n\n\n Which of the following non pharmacological interventions should the nurse<\/p>\n\n\n\n suggest to the client to reduce pain?<\/p>\n\n\n\n Alternate application of heat and cold to the affected joints.<\/p>\n\n\n\n 160.. A nurse is assessing a client who has diabetes insipidus. Which of the<\/p>\n\n\n\n following findings should the nurse expect?<\/p>\n\n\n\n Low urine specific gravity<\/p>\n\n\n\n 161.. A nurse is assessing an older adult client who has heart failure and takes<\/p>\n\n\n\n digoxin. Which of the following findings should the nurse recognize as an<\/p>\n\n\n\n indication of digoxin toxicity?<\/p>\n\n\n\n Bradycardia<\/p>\n\n\n\n 162.. A nurse is caring for a client 1 hr following a cardiac catheterization. The<\/p>\n\n\n\n nurse notes the formation of a hematoma at the insertion site and a decreased<\/p>\n\n\n\n pulse rate in the affected extremity. Which of the following interventions is the<\/p>\n\n\n\n nurse’s priority?<\/p>\n\n\n\n Apply firm pressure to the insertion site<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n 163.. A nurse is caring for a client who has a pneumothorax and a closed-chest<\/p>\n\n\n\n drainage system. Which of the following findings is an indication of lung re-<\/p>\n\n\n\n expansion?<\/p>\n\n\n\n Bubbling in the water-seal chamber has ceased.<\/p>\n\n\n\n 164.. A nurse is caring for a client who has a potassium level of 3 mEq\/L. Which of<\/p>\n\n\n\n the following assessment findings should the nurse expect?<\/p>\n\n\n\n Hypoactive bowel sounds<\/p>\n\n\n\n 165.. nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the<\/p>\n\n\n\n following should the nurse plan to administer?<\/p>\n\n\n\n Regular insulin (fast acting) 20 units IV bolus<\/p>\n\n\n\n Can be effective within 10 mins<\/p>\n\n\n\n Management: hydrate, correct acid-base imbalance (metabolic acidosis), &<\/p>\n\n\n\n decrease BGL)<\/p>\n\n\n\n 166.. A nurse is caring for a client who has HIV. Which of the following findings<\/p>\n\n\n\n indicates a positive response to the prescribed HIB treatment?<\/p>\n\n\n\n Decreased viral load<\/p>\n\n\n\n 167.. A nurse is caring for a client who is experiencing an acute myocardial<\/p>\n\n\n\n infarction. The nurse should identify which of the following findings as a<\/p>\n\n\n\n manifestation of cardiogenic shock?<\/p>\n\n\n\n Hypotension<\/p>\n\n\n\n 168.. A nurse is caring for a client who is eight hours post-operative<\/p>\n\n\n\n following a total hip arthroplasty the client is unable to void on the bed<\/p>\n\n\n\n pan Which of the following actions should the nurse take first<\/p>\n\n\n\n Scan the bladder with a portable ultrasound<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The first action should be using the nursing process which is assisting<\/p>\n\n\n\n the client scanning the bladder with a portable ultrasound device<\/p>\n\n\n\n will determine the amount of urine in the bladder<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n 169.. A nurse is teaching a client who has atrial fibrillation about the<\/p>\n\n\n\n purpose of wearing a Holter monitor. Which of the following<\/p>\n\n\n\n information should the nurse include in the teaching ?<\/p>\n\n\n\n This device can detect when you have an irregular heart rate<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Because Holter reports and transmits electrical impulses of the heart<\/p>\n\n\n\n and alerts the nurse to dysrhythmias myocardial injury or conduction<\/p>\n\n\n\n defects a Holter monitor allows the client freedom of movement while<\/p>\n\n\n\n cardiac activity is recorded.<\/p>\n\n\n\n 170.. A nurse is preparing a client for outpatient surgery. After the nurse inserts<\/p>\n\n\n\n the IV catheter, the client reports pain in the insertion area. Which of the<\/p>\n\n\n\n following actions should the nurse take?<\/p>\n\n\n\n Remove the catheter and insert another into a different site.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n It is possible that the catheter is up against a valve or near a nerve and is causing<\/p>\n\n\n\n more pain than an IV catheter insertion should. The nurse should remove the<\/p>\n\n\n\n source of the pain and establish peripheral IV access elsewhere.<\/p>\n\n\n\n 171..A nurse is reviewing the laboratory findings for a client who developed fat<\/p>\n\n\n\n embolism syndrome (FES) following a fracture. Which of the following<\/p>\n\n\n\n laboratory findings should the nurse expect?<\/p>\n\n\n\n Decreased serum calcium level<\/p>\n\n\n\n Rational<\/p>\n\n\n\n A decreased serum calcium level is an expected finding for FES, although the<\/p>\n\n\n\n reason for this finding is unknown.<\/p>\n\n\n\n 172.. A nurse is assessing a client who is in skeletal traction. Which of the<\/p>\n\n\n\n following findings should the nurse identify as an indication of infection at the pin<\/p>\n\n\n\n sites?<\/p>\n\n\n\n Fever<\/p>\n\n\n\n Rational<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n Manifestations of inflammation and infection at the pin sites include fever,<\/p>\n\n\n\n purulent drainage, odor, loose pins, and tenting of the skin around the pin sites.<\/p>\n\n\n\n 173.. A nurse is caring for a middle adult female client who reports that her<\/p>\n\n\n\n menstrual periods have become irregular and she has been having hot flashes.<\/p>\n\n\n\n The nurse should expect the client to have which of the following manifestations<\/p>\n\n\n\n associated with early menopause?<\/p>\n\n\n\n Dryness with intercourse<\/p>\n\n\n\n Menopause, the cessation of a woman’s menstrual periods, occurs when the<\/p>\n\n\n\n ovaries stop making estrogen. Because of the changes in the vagina, some women<\/p>\n\n\n\n can have dryness, discomfort, or pain during sexual intercourse.<\/p>\n\n\n\n 174.. A nurse is caring for a client who is receiving a unit of packed red blood cells.<\/p>\n\n\n\n Fifteen minutes following the start of the transfusion, the nurse notes that the<\/p>\n\n\n\n client is febrile, with chills and red-tinged urine. Which of the following<\/p>\n\n\n\n transfusion reactions should the nurse suspect?<\/p>\n\n\n\n Hemolytic<\/p>\n\n\n\n 175..A nurse is reviewing laboratory values for a client who has systemic lupus<\/p>\n\n\n\n erythematosus (SLE). Which of the following values should give the nurse the best<\/p>\n\n\n\n indication of the client’s renal function?<\/p>\n\n\n\n Serum creatinine<\/p>\n\n\n\n Rational<\/p>\n\n\n\n A renal function disorder reduces the excretion of creatinine, resulting in<\/p>\n\n\n\n increased levels of blood creatinine. Creatinine is a specific and sensitive indicator<\/p>\n\n\n\n of renal function.<\/p>\n\n\n\n 176.. A nurse is providing teaching to a client who has a new diagnosis of type 2<\/p>\n\n\n\n diabetes mellitus. The nurse should recognize that the client understands the<\/p>\n\n\n\n teaching when he identifies which of the following as manifestations of<\/p>\n\n\n\n hypoglycemia? (Select all that apply.)<\/p>\n\n\n\n Blurred vision<\/p>\n\n\n\n Tachycardia Moist,<\/p>\n\n\n\n clammy skin<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n 177.. A nurse is reviewing the arterial blood gas values of a client who has<\/p>\n\n\n\n chronic kidney disease. Which of the following sets of values should the nurse<\/p>\n\n\n\n expect? pH 7.25, HCO3- 19 mEq\/L, PaCO2 30 mm Hg<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse should expect a client who has renal failure to have metabolic acidosis,<\/p>\n\n\n\n which is characterized by a low HCO3-, a low pH, and a low or normal PaCO2.<\/p>\n\n\n\n Expected reference ranges for these laboratory values are as follows: pH 7.35 to<\/p>\n\n\n\n 7.45, HCO3- 21 to 28 mEq\/L, and PaCO2 35 to 45 mm Hg.<\/p>\n\n\n\n 178.. A nurse is caring for a client who has congestive heart failure and is taking<\/p>\n\n\n\n digoxin daily. The client refused breakfast and is complaining of nausea and<\/p>\n\n\n\n weakness. Which of the following actions should the nurse take first?<\/p>\n\n\n\n Check the client’s vital signs.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n It is possible that the client’s nausea is secondary to digoxin toxicity. By obtaining<\/p>\n\n\n\n vital signs, the nurse can assess for bradycardia, which is a symptom of digoxin<\/p>\n\n\n\n toxicity. The nurse should withhold the medication and call the provider if the<\/p>\n\n\n\n client’s heart rate is less than 60 bpm.<\/p>\n\n\n\n 179.. A nurse is teaching a female client who has a new diagnosis of<\/p>\n\n\n\n systemic lupuserythematosus(SLE).Thenurseshouldrecognizetheneed<\/p>\n\n\n\n forfurther teaching when the client identifies which of the following as a<\/p>\n\n\n\n factor that can exacerbate SLE?<\/p>\n\n\n\n Exercise<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Deconditioning and muscle atrophy occurs as a result of lack of mobility. The<\/p>\n\n\n\n nurse should encourage client to engage in conditioning exercises alternated with<\/p>\n\n\n\n periods of rest.<\/p>\n\n\n\n 180.. A nurse is caring for a client who has HIV. Which of the following laboratory<\/p>\n\n\n\n values is the nurse’s priority?<\/p>\n\n\n\n CD4-T-cell count 180 cells\/mm3<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n Rational<\/p>\n\n\n\n A CD4-T-cell count of less than 180 cells\/mm3 indicates that the client is severely<\/p>\n\n\n\n immunocompromised and is at high risk for infection. Therefore, this value is the<\/p>\n\n\n\n priority for the nurse to report to the provider.<\/p>\n\n\n\n 181.. A nurse is working with a licensed practical nurse (LPN) to care for a client<\/p>\n\n\n\n who is receiving a continuous IV infusion. Which of the following findings reported<\/p>\n\n\n\n by the LPN indicates to the nurse the client has phlebitis at the IV insertion site?<\/p>\n\n\n\n The area surrounding the insertion site feels warm to the touch.<\/p>\n\n\n\n 182.. A community health nurse is developing a pamphlet about breast self-<\/p>\n\n\n\n examination (BSE) for a local health fair. Which of the following instructions<\/p>\n\n\n\n should the nurse include?<\/p>\n\n\n\n Breasts can be examined in the shower with soapy hands.<\/p>\n\n\n\n The nurse should encourage clients to perform a BSE or do an extra examination<\/p>\n\n\n\n while showering. This allows clients to concentrate more easily on feeling for<\/p>\n\n\n\n tissue changes.<\/p>\n\n\n\n 183.. A nurse is caring for four clients. Which of the following clients is at greatest<\/p>\n\n\n\n risk for a pulmonary embolism.<\/p>\n\n\n\n A client who is 12 hr postoperative following a total hip arthroplasty<\/p>\n\n\n\n 184.. nurse is assessing a client with diabetes insipidus. The nurse knows that<\/p>\n\n\n\n which assessment finding is typical of this condition?<\/p>\n\n\n\n Polyuria<\/p>\n\n\n\n 185.. A nurse is caring for a client after a craniotomy for pituitary tumor who<\/p>\n\n\n\n has developeddiabetes insipidus.Theclientisreceiving vasopressin (Pitressin).<\/p>\n\n\n\n The desired response to the medication is evident when the nurse observes<\/p>\n\n\n\n which of the following findings?<\/p>\n\n\n\n A decrease in urine output.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The major manifestations of diabetes insipidus are excessive urination and<\/p>\n\n\n\n extreme thirst. Pitressin is used to control frequent urination, increased thirst,<\/p>\n\n\n\n and<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n loss of water associated with diabetes insipidus. A decreased urine output is the<\/p>\n\n\n\n desired response.<\/p>\n\n\n\n 186.. A nurse in a providers office is reviewing lab results of a client who is being<\/p>\n\n\n\n evaluated for secondary hypothyroidism. Which of the following lab findings is<\/p>\n\n\n\n expected for a client who has this condition?<\/p>\n\n\n\n Decreased serum T3<\/p>\n\n\n\n 187.. A nurse is reviewing the medical record of a client who is taking warfarin<\/p>\n\n\n\n for chronicatrialfibrillation. Which ofthefollowing valuesshould thenurse<\/p>\n\n\n\n identify as a desired outcome for this therapy<\/p>\n\n\n\n INR 2.5<\/p>\n\n\n\n 188..A nurse is providing teaching for a female client who has recurrent urinary<\/p>\n\n\n\n tract infections. Which of the following information should the nurse include in<\/p>\n\n\n\n the teaching?<\/p>\n\n\n\n Void before and after intercourse<\/p>\n\n\n\n 189.. A nurse is caring for a client who has increased intracranial pressure (ICP)<\/p>\n\n\n\n and is receiving mannitol via continuous IV infusion. The nurse should report<\/p>\n\n\n\n which of the following adverse effects of this medication to the provider?<\/p>\n\n\n\n Crackles heard on auscultation<\/p>\n\n\n\n 190.. A nurse is providing teaching to a client who has breast cancer about the<\/p>\n\n\n\n adverse effects of chemotherapy. Which of the following client statements<\/p>\n\n\n\n indicates an understanding of the teaching?<\/p>\n\n\n\n I’ll call my doctor if I notice any unusual menstrual bleeding.<\/p>\n\n\n\n 191.. A nurse is caring for a client who has chemotherapy- induced<\/p>\n\n\n\n peripheral neuropathy.Thenurseshouldexpecttheclienttoreporthaving<\/p>\n\n\n\n experienced which of the following symptoms?<\/p>\n\n\n\n Tingling feeling in the extremities<\/p>\n\n\n\n Peripheral neuropathy is a neurological disorder resulting from damage to the<\/p>\n\n\n\n peripheral nerves. It may be caused by diseases of the nerves, systemic illnesses,<\/p>\n\n\n\n or it may be a side-effect from chemotherapy. If a sensory nerve is damaged, the<\/p>\n\n\n\n client is likely to experience pain, numbness, tingling, burning, or a loss of feeling<\/p>\n\n\n\n in the extremities.<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n 192.. A nurse is providing discharge teaching for a client who is postoperative following<\/p>\n\n\n\n a simple mastectomy. The client is to begin outpatient radiation therapy the next day.<\/p>\n\n\n\n Which of the following instructions about maintaining skin integrity should the nurse<\/p>\n\n\n\n include?<\/p>\n\n\n\n Do not apply heat to the area of irradiation.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n This instruction will help the client avoid tissue damage. Radiated tissue becomes thinner<\/p>\n\n\n\n and might lack tissue receptors that would otherwise alert the client to a potential burn<\/p>\n\n\n\n injury. When outdoors in sunlight, the client should wear protective clothing over the<\/p>\n\n\n\n area of irradiation.<\/p>\n\n\n\n 193.. A nurse is caring for a client who is being evaluated for acromegaly. Which of<\/p>\n\n\n\n the following manifestations should the nurse expect to find during assessment?<\/p>\n\n\n\n (Select all that apply.)<\/p>\n\n\n\n Diaphoresis<\/p>\n\n\n\n Coarse facial features<\/p>\n\n\n\n Enlarged distal extremities is correct.<\/p>\n\n\n\n Muscle weakness is correct.<\/p>\n\n\n\n Diaphoresis<\/p>\n\n\n\n Acromegaly is a chronic metabolic disorder caused by an excess of growth<\/p>\n\n\n\n hormone after normal growth of the skeleton and other organs is complete. The<\/p>\n\n\n\n physical manifestations associated with acromegaly include enlarged sebaceous<\/p>\n\n\n\n glands with excessive sweating.<\/p>\n\n\n\n Coarse facial features is correct.<\/p>\n\n\n\n The physical manifestations associated with acromegaly include enlarged facial<\/p>\n\n\n\n bones with thickening of the skin, leading to coarse facial features.<\/p>\n\n\n\n Enlarged distal extremities is correct. The physical manifestations associated with<\/p>\n\n\n\n acromegaly include enlarged hands and feet with thickening of the skin.<\/p>\n\n\n\n Muscle weakness is correct. The physical manifestations associated with<\/p>\n\n\n\n acromegaly include fatigue and muscle weakness.<\/p>\n\n\n\n 194.. A nurse in the post-anesthesia care unit is caring for a client who is postoperative<\/p>\n\n\n\n following a thoracotomy and lobectomy. Which of the following postoperative<\/p>\n\n\n\n assessments should the nurse give highest priority to?<\/p>\n\n\n\n Arterial blood gases<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n Rational<\/p>\n\n\n\n According to the ABC priority-setting framework, the postoperative surgical client may<\/p>\n\n\n\n need supplemental oxygen in order to maintain normal blood oxygen levels. The<\/p>\n\n\n\n effectiveness of oxygenation is monitored using pulse oximetry and arterial blood<\/p>\n\n\n\n gases.<\/p>\n\n\n\n 195.. A nurse is reviewing discharge instructions with a client following a right<\/p>\n\n\n\n cataract extraction. Which of the following instructions should the nurse include?<\/p>\n\n\n\n Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.<\/p>\n\n\n\n The nurse should instruct the client to avoid activities that increase intraocular<\/p>\n\n\n\n pressure.<\/p>\n\n\n\n Therefore, the nurse should instruct the client to avoid lifting anything heavier than<\/p>\n\n\n\n 4.5 kg (10 lb) for 1 week following surgery.<\/p>\n\n\n\n 196.. A nurse is teaching a client about the seven warning signs of cancer. Which of the<\/p>\n\n\n\n following signs should the nurse include as manifestations of cancer? (Select all that<\/p>\n\n\n\n apply.)<\/p>\n\n\n\n A nonhealing sore<\/p>\n\n\n\n Incorrect. Bloating<\/p>\n\n\n\n Change in bowel pattern<\/p>\n\n\n\n Change in moles<\/p>\n\n\n\n Nagging cough<\/p>\n\n\n\n 197.. A nurse is caring for a client who has expressive aphasia following a<\/p>\n\n\n\n cerebrovascular accident (CVA). Which of the following parameters should the nurse<\/p>\n\n\n\n use first in order to assess the client’s pain level?<\/p>\n\n\n\n a self-report pain rating scale<\/p>\n\n\n\n 198.. A nurse is caring for a client who is hospitalized with active pulmonary<\/p>\n\n\n\n tuberculosis and is started on ethambutol therapy. The nurse should understand that<\/p>\n\n\n\n which of the following should be monitored?<\/p>\n\n\n\n Visual acuity<\/p>\n\n\n\n Rational<\/p>\n\n\n\n A significant adverse effect of ethambutol is optic neuritis, vision loss, and loss of<\/p>\n\n\n\n color discrimination, especially red and green. Baseline vision testing should be<\/p>\n\n\n\n performed before use, and visual acuity monitored at regular intervals.<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n 199.. A nurse in a clinic is teaching information about cervical polyps with a client<\/p>\n\n\n\n who has a new diagnosis. Which ofthe following information should the nurse include<\/p>\n\n\n\n in the teaching?<\/p>\n\n\n\n Postcoital bleeding may occur.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The client may experience postcoital bleeding, because the polyps are soft, fragile,<\/p>\n\n\n\n and bleed when touched.<\/p>\n\n\n\n 200.. A nurse is providing teaching to a client who has breast cancer about the<\/p>\n\n\n\n adverse effects of chemotherapy. Which of the following client statements<\/p>\n\n\n\n indicates an understanding of the teaching?<\/p>\n\n\n\n I’ll call my doctor if I notice any unusual menstrual bleeding.<\/p>\n\n\n\n 201.. A nurse is teaching a client who has vulvodynia about self-care measures to<\/p>\n\n\n\n alleviate symptoms. Which statement by the client indicates an understanding of the<\/p>\n\n\n\n teaching?<\/p>\n\n\n\n I should avoid the use of any lubricants<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse should recommend the use of natural oils such as olive oil for lubricant and<\/p>\n\n\n\n avoid lubricants containing propylene glycol.<\/p>\n\n\n\n “I should wear cotton undergarments.”<\/p>\n\n\n\n White cotton underwear is recommended for the client with vulvodynia.<\/p>\n\n\n\n 202.. A staff nurse is teaching a client who has Addison’s disease about the disease<\/p>\n\n\n\n process. The client asks the nurse what causes Addison’s disease. Which of the<\/p>\n\n\n\n following responses should the nurse make?<\/p>\n\n\n\n It is caused by the lack of production of aldosterone by the adrenal gland.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Addison’s disease is caused by a lack of production of the adrenocorticotropic<\/p>\n\n\n\n hormones (cortisol and aldosterone) by the adrenal gland.<\/p>\n\n\n\n “It is caused by the overproduction of growth hormone by the pituitary gland.”<\/p>\n\n\n\n A client who has an overproduction of the growth hormone has acromegaly.<\/p>\n\n\n\n “It is caused by the overproduction of parathormone by the parathyroid<\/p>\n\n\n\n gland.”<\/p>\n\n\n\n A client who has hyperparathyroidism produces an excessive amount of parathormone.<\/p>\n\n\n\n 202.. A nurse is planning care for a female client who has a T4 spinal cord injury and is<\/p>\n\n\n\n at risk for acquiring urinary tract infections. Which of the following actions should the<\/p>\n\n\n\n nurse include in the client’s plan of care?<\/p>\n\n\n\n Encourage fluid intake at and between meals.<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Increased fluid intake dilutes the urine, reduces stasis, and greatly reduces the urinary<\/p>\n\n\n\n bacterial count. Consequently, the risk of nosocomial (hospital-acquired) UTI is<\/p>\n\n\n\n reduced, even for a client who has a spinal cord injury.<\/p>\n\n\n\n 203.. A nurse in an emergency department is caring for a client who has a<\/p>\n\n\n\n sucking chest wound resulting from a gunshot. The client has a blood pressure of<\/p>\n\n\n\n 100\/60 mm Hg, a weak pulse rate of 118\/min, and a respiratory rate of 40\/min.<\/p>\n\n\n\n Which of the following actions should the nurse take?<\/p>\n\n\n\n Administer oxygen via nasal cannula.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The client has an increased respiratory rate and heart rate, indicating that she is<\/p>\n\n\n\n having respiratory difficulty. The sucking chest wound indicates the client has a<\/p>\n\n\n\n pneumothorax and\/or a hemothorax. Administering oxygen will increase the<\/p>\n\n\n\n oxygen exchange in the lungs and the oxygen available to the tissues.<\/p>\n\n\n\n 204.. A nurse is teaching a client who has septic shock about the development of<\/p>\n\n\n\n disseminated intravascular coagulation (DIC). Which of the following statements<\/p>\n\n\n\n should the nurse make?<\/p>\n\n\n\n DIC is caused by abnormal coagulation involving fibrinogen.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n DIC is caused by abnormal coagulation involving the formation of multiple small<\/p>\n\n\n\n clots that consume clotting factors and fibrinogen faster than the body can produce<\/p>\n\n\n\n them, increasing the risk for hemorrhage.<\/p>\n\n\n\n 205.. A nurse is providing dietary teaching to a client who has a history of<\/p>\n\n\n\n recurring calcium oxalate kidney stones. Which of the following instructions<\/p>\n\n\n\n should the nurse include in the teaching?<\/p>\n\n\n\n Drink 3 L of fluid every day.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse should instruct the client to drink at least 3 to 4 L of fluid every day to<\/p>\n\n\n\n dilute the urine and reduce the risk for stone formation.<\/p>\n\n\n\n 206..A nurse is caring for a client who is experiencing menopausal symptoms and<\/p>\n\n\n\n asks the nurse about menopausal hormone therapy (HT). The nurse should inform<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n the client that HT is not recommended due to which of the following findings<\/p>\n\n\n\n in the client’s medical history?<\/p>\n\n\n\n History of breast cancer<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Women with a history of breast cancer should be counseled against using HT.<\/p>\n\n\n\n 207..A home health nurse is assessing an older adult client in the home who<\/p>\n\n\n\n has decreasedvisionduetoahistoryofglaucoma.Whichofthefollowing<\/p>\n\n\n\n findings should the nurse identify as a safety risk?<\/p>\n\n\n\n Scatter rugs are present in the kitchen.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Scatter rugs in the kitchen are a safety hazard. The client could trip on one of<\/p>\n\n\n\n the rugs and fall due to impaired vision.<\/p>\n\n\n\n 208.. A nurse is preparing a client for a radiation treatment who is postoperative<\/p>\n\n\n\n following a mastectomy. The nurse should inform the client to expect which of the<\/p>\n\n\n\n following adverse effects from the treatment?<\/p>\n\n\n\n Fatigue<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse should inform the client to expect fatigue with her radiation treatment.<\/p>\n\n\n\n Fatigue occurs regardless of the radiation target site.<\/p>\n\n\n\n Alopecia<\/p>\n\n\n\n Alopecia is an acute adverse effect of radiation to the brain.<\/p>\n\n\n\n Diarrhea<\/p>\n\n\n\n Diarrhea is an acute adverse effect of radiation to the abdomen and pelvis.<\/p>\n\n\n\n 209.. After radiation treatment, a client reports dryness, redness, and scaling of his<\/p>\n\n\n\n skin occurring within the designated radiation treatment markings. The nurse<\/p>\n\n\n\n should instruct the client to take which of the following actions?<\/p>\n\n\n\n Apply hydrating lotions.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The nurse should instruct the client to gently apply hydrating lotions that do not<\/p>\n\n\n\n contain metal, alcohol, or perfume.<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n 210.. A nurse is assessing a client who is in skeletal traction. Which of the<\/p>\n\n\n\n following findings should the nurse identify as an indication of infection at the pin<\/p>\n\n\n\n sites?<\/p>\n\n\n\n Fever<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Manifestations of inflammation and infection at the pin sites include fever,<\/p>\n\n\n\n purulent drainage, odor, loose pins, and tenting of the skin around the pin sites.<\/p>\n\n\n\n 211..A nurse on a medical-surgical unit is caring for four clients who are 24 to 36<\/p>\n\n\n\n hr postoperative. Which of the following surgical procedures places the client at<\/p>\n\n\n\n risk for deep-vein thrombosis?<\/p>\n\n\n\n Hip arthroplasty<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Clients who are postoperative following orthopedic procedures of the lower<\/p>\n\n\n\n extremities and clients who were placed in the lithotomy position for a procedure,<\/p>\n\n\n\n such as for gynecological or urological surgeries, are at a higher risk of<\/p>\n\n\n\n developing deep-vein thrombosis postoperatively.<\/p>\n\n\n\n 212.. A nurse is caring for a client who is 2 hr postoperative following a<\/p>\n\n\n\n transurethral resection of the prostate (TURP) gland. Which of the following<\/p>\n\n\n\n assessments should the nurse view to be an indication of a postoperative<\/p>\n\n\n\n complication?<\/p>\n\n\n\n Output of burgundy colored urine<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Output of burgundy colored urine may indicate venous bleeding, a potential<\/p>\n\n\n\n complication following a TURP. S<\/p>\n\n\n\n 213.. A nurse is assessing a client before administering a unit of packed RBCs.<\/p>\n\n\n\n The nurseshould identifywhich of thefollowing data as most importantto obtain<\/p>\n\n\n\n prior to the infusion?<\/p>\n\n\n\n Temperature<\/p>\n\n\n\n Rational<\/p>\n\n\n\n The greatest risk to the client is injury from a blood transfusion reaction.<\/p>\n\n\n\n Therefore, the priority action is to take a baseline temperature measurement. The<\/p>\n\n\n\n nurse should then monitor the client’s temperature throughout the infusion as an<\/p>\n\n\n\n increase in temperature can indicate an adverse reaction.<\/p>\n\n\n\n ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +<\/p>\n\n\n\n 214.. A nurse in an ophthalmology clinic is interviewing a client who was referred<\/p>\n\n\n\n by his primary care provider for suspicion of cataracts. The nurse should expect the<\/p>\n\n\n\n client to report?<\/p>\n\n\n\n Having a decreased ability to perceive colors.<\/p>\n\n\n\n Rational<\/p>\n\n\n\n Symptoms of cataracts include painless blurred vision and a decrease in the ability<\/p>\n\n\n\n to perceive colors.<\/p>\n\n\n\n 215.. A nurse is evaluating a client’s laboratory results. The nurse should recognize<\/p>\n\n\n\n that an increase in the client’s prostate specific antigen (PSA) laboratory value is<\/p>\n\n\n\n indicative of which of the following diagnoses?<\/p>\n\n\n\n Prostatic cancer<\/p>\n\n\n\n 216.. A nurse is providing postoperative care for a client who has two chest tubes<\/p>\n\n\n\n in place following a lobectomy. The client asks the nurse the reason for having<\/p>\n\n\n\n two chest tubes. The nurse should inform the client that the lower chest tube is<\/p>\n\n\n\n placed for which of the following reasons?<\/p>\n\n\n\n draining blood and fluid from the pleural space<\/p>\n\n\n\n 217.. A nurse is working with an assistive personnel (AP) who is assigned to bathe<\/p>\n\n\n\n a client who has herpes zoster. The AP asks the nurse if the herpes zoster is<\/p>\n\n\n\n contagious. Which of the following responses should the nurse make?<\/p>\n\n\n\n Herpes zoster is not contagious to people who have had chickenpox<\/p>\n\n\n\n 218.. A nurse is caring for a client who is receiving total parenteral nutrition (TPN).<\/p>\n\n\n\n Which of the following actions should the nurse take?<\/p>\n\n\n\n check the clients capillary blood glucose level every 4 hr<\/p>\n\n\n\n ATI Proctored Exam Medical Surgical Form A<\/p>\n\n\n\n 1. A nurse is teaching a client about the use of an incentive spirometer. Which of the following<\/p>\n\n\n\n instructions should the nurse include in the teaching?<\/p>\n\n\n\n -Place hands on the upper abdomen during inhalation.<\/p>\n\n\n\n -Exhale slowly through pursed lips.<\/p>\n\n\n\n -Hold breath about 3 to 5 seconds before exhaling. (ATI page 138)<\/p>\n\n\n\n -Position the mouthpiece 2.5 cm (1 in) from the mouth.<\/p>\n\n\n\n 2. A nurse is assessing a client who is 12 hr. postoperative following a colon resection. Which of<\/p>\n\n\n\n the following findings should the nurse report to the surgeon?<\/p>\n\n\n\n -Heart rate 90\/mm<\/p>\n\n\n\n -Hgb 8.2 g\/dL<\/p>\n\n\n\n -Gastric ph of 3.0<\/p>\n\n\n\n -Absent bowel sounds<\/p>\n\n\n\n Recall that bowel sounds are altered in patients with obstruction; absent bowel sounds imply<\/p>\n\n\n\n total obstruction. QSEN: Safety (Book page 1143)<\/p>\n\n\n\n 3. A nurse is caring for a client who has diabetes insipidus. Which of the following medications<\/p>\n\n\n\n should the nurse plan to administer?<\/p>\n\n\n\n -Regular Insulin<\/p>\n\n\n\n -Furosemide<\/p>\n\n\n\n -Desmopressin<\/p>\n\n\n\n -Lithium Carbonate<\/p>\n\n\n\n Teach patients with diabetes insipidus the proper way to self-administer desmopressin orally or<\/p>\n\n\n\n by nasal spray.<\/p>\n\n\n\n Management focuses on controlling symptoms with drug therapy.<\/p>\n\n\n\n -The most preferred drug is desmopressin acetate (DDAVP), a synthetic form of<\/p>\n\n\n\n vasopressin given orally, as a sublingual \u201cmelt,\u201d or intranasally in a metered spray. The<\/p>\n\n\n\n frequency of dosing varies with patient responses. Teach patients that each metered spray<\/p>\n\n\n\n delivers 10 mcg and those with mild DI may need only one or two doses in 24 hours.<\/p>\n\n\n\n -For more severe DI, one or two metered doses two or three times daily may be needed.<\/p>\n\n\n\n 4. A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times<\/p>\n\n\n\n daily for 3 years. Which of the following test should the nurse monitor?<\/p>\n\n\n\n Stool occult blood<\/p>\n\n\n\n -Urine for white blood cells<\/p>\n\n\n\n -Fasting blood glucose<\/p>\n\n\n\n -Serum calcium<\/p>\n\n\n\n 5. A nurse is preparing to administer thrombolytic therapy to a client who had an ischemic<\/p>\n\n\n\n stroke. Which of the following is an appropriate nursing action?<\/p>\n\n\n\n -Start the therapy within 8 hrs. (within 6 hrs.)<\/p>\n\n\n\n -Insert an indwelling urinary catheter after therapy begins<\/p>\n\n\n\n -Monitor blood pressure every 30 minutes during infusion.<\/p>\n\n\n\n MARTINE ROSS 1<\/p>\n\n\n\n -Elevate the head of the bed between 25 and 30 degrees (to reduce ICP & promote venous<\/p>\n\n\n\n drainage, ATI page 89)<\/p>\n\n\n\n MARTINE ROSS 2<\/p>\n\n\n\n Assess for drug-related blood loss such as that caused by NSAIDs bychecking the stool for<\/p>\n\n\n\n gross oroccultblood.Older white women are the most likely to experience GI bleeding as<\/p>\n\n\n\n a result of taking these medications. (Book page 324)<\/p>\n\n\n\n 6. A nurse in the emergency department is assessing a client. Which of the following actions<\/p>\n\n\n\n should the nurse take first? (Click on the \u201cExhibit\u201d button for additional information about the<\/p>\n\n\n\n client. There are three tabs that contain separate categories of data.)<\/p>\n\n\n\n -Obtain a sputum sample for culture.<\/p>\n\n\n\n -Prepare the client for a chest x-ray.<\/p>\n\n\n\n -Initiate airborne precautions (question sounds like a respiratory issue)<\/p>\n\n\n\n -Administer ondansetron.<\/p>\n\n\n\n 7. A nurse is admitting a client who reports chest pain and has been placed on a telemetry<\/p>\n\n\n\n monitor. Which of the following should the nurse analyze to determine whether the client<\/p>\n\n\n\n is experiencing a myocardial infarction?<\/p>\n\n\n\n -QRS duration<\/p>\n\n\n\n -ST segment<\/p>\n\n\n\n -T-wave<\/p>\n\n\n\n PR interval<\/p>\n\n\n\n Examine the ST segment. The normal ST segment begins at the isoelectric line. ST elevation<\/p>\n\n\n\n or depression is significant if displacement is 1 mm (one small box) or more above or below<\/p>\n\n\n\n the line and is seen in two or more leads. ST elevation may indicate problems such as<\/p>\n\n\n\n myocardial infarction, pericarditis, and hyperkalemia. ST depression is associated with<\/p>\n\n\n\n hypokalemia, myocardial infarction, or ventricular hypertrophy. (Book page 670)<\/p>\n\n\n\n 8. A nurse is teaching a client who has ovarian cancer about skin care following<\/p>\n\n\n\n radiation treatment. Which of the following instructions should the nurse include?<\/p>\n\n\n\n -Apply over the counter moisturizer to the radiation site<\/p>\n\n\n\n -Cover the radiation site loosely with a gauze wrap before dressing<\/p>\n\n\n\n -Use a soft washcloth to clean the area around the radiation site<\/p>\n\n\n\n -Pat the skin on the radiation site to dry it. (Book page 390)<\/p>\n\n\n\n Skin Protection During Radiation Therapy<\/p>\n\n\n\n \u2022 Wash the irradiated area gently each day with either water or a mild soap and water<\/p>\n\n\n\n as prescribed by your radiation therapy team.<\/p>\n\n\n\n 9. A nurse is contacting the provider of a client who has cancer and is experiencing<\/p>\n\n\n\n breakthrough pain. Which of the following prescriptions should the nurse anticipate?<\/p>\n\n\n\n -Intravenous dexamethasone<\/p>\n\n\n\n -Transmucosal fentanyl<\/p>\n\n\n\n -Oral acetaminophen- not strong enough<\/p>\n\n\n\n -Intramuscular meperidine<\/p>\n\n\n\n Fentanyl is a lipophilic (readily absorbed in fatty tissue) opioid and, as such, has a fast onset<\/p>\n\n\n\n and short duration of action. It is recommended opioid for patients with end-organ failure<\/p>\n\n\n\n because it has no clinically relevant metabolites. It also produces fewer hemodynamic adverse<\/p>\n\n\n\n effects than other opioids; therefore, it is often preferred in patients who are hemodynamically<\/p>\n\n\n\n unstable such as the critically ill. (Book page 59)<\/p>\n\n\n\n \u2022 Use your hand rather than a washcloth when cleansing the therapy site to be gentler.<\/p>\n\n\n\n \u2022 Rinse soap thoroughly from your skin.<\/p>\n\n\n\n \u2022 If ink or dye markings are present to identify exactly where the beam of radiation is to be<\/p>\n\n\n\n focused, take care not to remove them.<\/p>\n\n\n\n \u2022Dry the irradiated area with patting rather than rubbing motions; use a clean, soft towel or<\/p>\n\n\n\n cloth.<\/p>\n\n\n\n \u2022 Use only powders, ointments, lotions, or creams that are prescribed by the radiation oncology<\/p>\n\n\n\n department on your skin at the radiation site.<\/p>\n\n\n\n \u2022 Wear soft clothing over the skin at the radiation site.<\/p>\n\n\n\n \u2022 Avoid wearing belts, buckles, straps, or any type of clothing that binds or rubs the skin at the<\/p>\n\n\n\n radiation site.<\/p>\n\n\n\n \u2022 Avoid exposure of the irradiated area to the sun:<\/p>\n\n\n\n \u2022 Protect this area by wearing clothing over it.<\/p>\n\n\n\n \u2022 Try to go outdoors in the early morning or evening to avoid the more intense sun rays.<\/p>\n\n\n\n \u2022 When outdoors, stay under awnings, umbrellas, and other forms of shade during the times when<\/p>\n\n\n\n the sun’s rays are most intense (10 AM to 7 PM).<\/p>\n\n\n\n \u2022 Avoid heat exposure.<\/p>\n\n\n\n 10. A nurse is caring for a client who is receiving a blood transfusion. The nurse observes that<\/p>\n\n\n\n the client has bounding peripheral pulses, hypertension, and distended jugular veins. The<\/p>\n\n\n\n nurse should anticipate administering which of the following prescribed medications?<\/p>\n\n\n\n Acetaminophen<\/p>\n\n\n\n -Furosemide (this patient has fluid overload from the transfusion)<\/p>\n\n\n\n Diphenhydramine<\/p>\n\n\n\n Pantoprazole<\/p>\n\n\n\n 11. A nurse is assessing a client who is receiving magnesium sulfate IV for the treatment of<\/p>\n\n\n\n hypomagnesemia. Which of the following findings indicates effectiveness of the medication?<\/p>\n\n\n\n -Lungs clear<\/p>\n\n\n\n -Hypoactive bowel sounds- Reduced motility, anorexia, nausea, constipation, and abdominal<\/p>\n\n\n\n distention are common. A paralytic ileus may occur when hypomagnesemia is severe.<\/p>\n\n\n\n -Blood pressure 90\/50 mm Hg-hypomagnesemia causes hypertension, but this is too low,<\/p>\n\n\n\n abnormal<\/p>\n\n\n\n -Apical pulse 82\/min<\/p>\n\n\n\n One aspect of the conduction problems is that, when serum magnesium levels are low,<\/p>\n\n\n\n intracellular potassium levels are also low. This changes the resting membrane potential in<\/p>\n\n\n\n cardiac muscle cells, slowing normal conduction and triggering ectopic beats.<\/p>\n\n\n\n 12. A nurse is preparing a client for a lumbar puncture. Which of the following images indicates<\/p>\n\n\n\n the position the nurse should assist the client into for this procedure?<\/p>\n\n\n\n – \u201cCannonball position on the side\u201d picture #4 (ATI page 20)<\/p>\n\n\n\n 13. A nurse is reviewing a clients ABG results: pH 7.42, PaCO2 30 mm Hg, and HCO3 -21<\/p>\n\n\n\n mEq\/L. The nurse should recognize these findings as an indication of which of the<\/p>\n\n\n\n following conditions?<\/p>\n\n\n\n -Compensated respiratory alkalosis<\/p>\n\n\n\n -Uncompensated respiratory acidosis<\/p>\n\n\n\n -Metabolic acidosis<\/p>\n\n\n\n -Metabolic alkalosis<\/p>\n\n\n\n 14. A nurse is preparing to administer daily medications to a client who is undergoing a<\/p>\n\n\n\n procedure at 1000 that requires IV contrast dye. Which of the following routine medications<\/p>\n\n\n\n to give at 0800 should the nurse withhold?<\/p>\n\n\n\n -Metoprolol<\/p>\n\n\n\n -Metformin<\/p>\n\n\n\n -Fluticasone<\/p>\n\n\n\n -Valproic Acid<\/p>\n\n\n\n 15. A nurse is planning care for a client who is experiencing seizures secondary to meningitis.<\/p>\n\n\n\n Which of the following interventions should the nurse include in the plan of care? (Select all<\/p>\n\n\n\n that apply.)<\/p>\n\n\n\n -Assist the client to ambulate every 4 hr.<\/p>\n\n\n\n -Place a tongue blade at the bedside.<\/p>\n\n\n\n -Have suction equipment at the bedside.<\/p>\n\n\n\n -Dim the overhead lights.<\/p>\n\n\n\n -Apply a warming blanket.<\/p>\n\n\n\n 16. A nurse is caring for a client who has a pressure ulcer with necrotic tissue and requires wet<\/p>\n\n\n\n to damp dressing changes daily. Which of the following types of debridement should the nurse<\/p>\n\n\n\n include in the plan of care?<\/p>\n\n\n\n -Enzymatic<\/p>\n\n\n\n -Surgical<\/p>\n\n\n\n -Autolytic<\/p>\n\n\n\n -Mechanical<\/p>\n\n\n\n 17. A nurse is caring for a female who has toxic shock syndrome. Which of the following<\/p>\n\n\n\n findings should the nurse expect?<\/p>\n\n\n\n -Elevated platelet count<\/p>\n\n\n\n -Decreased total bilirubin<\/p>\n\n\n\n -Generalized rash<\/p>\n\n\n\n -Hypertension<\/p>\n\n\n\n 18. A nurse is preparing to administer a medication for a client though a non-tunneled<\/p>\n\n\n\n percutaneous central catheter. Which of the following actions should the nurse take?<\/p>\n\n\n\n -Close the inline clamp<\/p>\n\n\n\n -Apply a local anesthetic to the skin<\/p>\n\n\n\n -Don sterile gloves<\/p>\n\n\n\n -Flush the catheter with 10 mL of 0.9% sodium chloride.<\/p>\n\n\n\n 19. A nurse is caring for a client who was admitted with nausea, vomiting, and a possible<\/p>\n\n\n\n bowel obstruction. An NG tube is placed and set to a low intermittent suction. Which of the<\/p>\n\n\n\n following findings should the nurse report to the provider?<\/p>\n\n\n\n -The client reports being extremely thirst with a sore throat<\/p>\n\n\n\n -The drainage is bright green in color with brown fecal material<\/p>\n\n\n\n -The amount of drainage is gradually decreasing<\/p>\n\n\n\n -The client\u2019s abdomen becomes distended and firm.<\/p>\n\n\n\n 20. A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of the<\/p>\n\n\n\n following findings should the nurse expect?<\/p>\n\n\n\n -Elevated blood pressure<\/p>\n\n\n\n -Hypothermia<\/p>\n\n\n\n -Urine specific gravity 1.001<\/p>\n\n\n\n -Bun 15 mg\/d:<\/p>\n\n\n\n 21. The nurse is caring for a client who has hyperthyroidism and develops thyroid storm. Which<\/p>\n\n\n\n of the following instructions should the nurse give to the client regarding management of thyroid<\/p>\n\n\n\n storm?<\/p>\n\n\n\n -You will need to begin taking an ACE inhibition medication<\/p>\n\n\n\n -You will need a pacemaker to increase your heart rate<\/p>\n\n\n\n -You will need a cooling blanket to lower your body temperature<\/p>\n\n\n\n -You will need additional thyroid supplementation<\/p>\n\n\n\n 22. The nurse is reviewing the medical record of a client who has acute gout. The nurse<\/p>\n\n\n\n should expect an increase in which of the following laboratory results?<\/p>\n\n\n\n -Uric acid<\/p>\n\n\n\n -Intrinsic factor<\/p>\n\n\n\n -Creatinine kinase<\/p>\n\n\n\n -Chloride level<\/p>\n\n\n\n 23. A nurse is preparing to administer peritoneal dialysis to a client. Which of the following<\/p>\n\n\n\n actions should the nurse take?<\/p>\n\n\n\n -Use clean technique to access the catheter<\/p>\n\n\n\n -Chill the dialysate before administration<\/p>\n\n\n\n -Hang the drainage bag below the client\u2019s abdomen<\/p>\n\n\n\n -Place the client in high-Fowler\u2019s position.<\/p>\n\n\n\n 24. A nurse in the emergency department is caring for a client who has deep partial thickness<\/p>\n\n\n\n burns over 30% of his body, including his upper chest and abdomen. Which of the following<\/p>\n\n\n\n actions is the nurse priority?<\/p>\n\n\n\n -Insert an 18-gauge IV catheter<\/p>\n\n\n\n -Administer tetanus toxoid<\/p>\n\n\n\n -Check the clients mouth for black particles<\/p>\n\n\n\n -Remove the clients burned clothing.Document continues below<\/p>\n\n\n\n Discover more from:<\/strong><\/p>\n\n\n\n Community health nursing (NUR 2611)<\/a><\/strong>(NUR 2611)<\/p>\n\n\n\n 396 documentsGo to course<\/p>\n\n\n\n 25. A nurse is presenting an in-service program about Parkinson\u2019s disease (PD). Which of the<\/p>\n\n\n\n following statements should the nurse include in teaching?<\/p>\n\n\n\n -PD results form a decreased amount of dopamine in the client\u2019s brain<\/p>\n\n\n\n -PD causes clients to have an increased sympathetic nervous system response<\/p>\n\n\n\n -PD results in the development of neurofibrillary tangles within the client\u2019s brain<\/p>\n\n\n\n -PD manifestations worsen due to the clients decreased production of acetylcholine<\/p>\n\n\n\n 26. A nurse is caring for a client who has a serum sodium level of 150 mEq\/L. Which of<\/p>\n\n\n\n the following actions should the nurse take?<\/p>\n\n\n\n -Increase sodium in the client\u2019s diet<\/p>\n\n\n\n -Administer hypotonic IV fluids to the client<\/p>\n\n\n\n -Restrict the client\u2019s oral fluid intake<\/p>\n\n\n\n -Administer a beta blocker<\/p>\n\n\n\n 27. A nurse is caring for a client who takes lisinopril for hypertension. Which of the following<\/p>\n\n\n\n client statements indicates an adverse effect of the medication?<\/p>\n\n\n\n -I seem to be bruising more easily<\/p>\n\n\n\n -I have a nagging, dry cough<\/p>\n\n\n\n -I have a heightened sense of taste<\/p>\n\n\n\n -I have to urinate frequently<\/p>\n\n\n\n 28. A nurse is providing discharge teaching to a client following a modified left mastectomy with<\/p>\n\n\n\n breast expander. Which of the following statements by the client indicates an understanding of<\/p>\n\n\n\n the teaching?<\/p>\n\n\n\n -I will perform strength-building arm exercises using a 15-pound weight<\/p>\n\n\n\n -I should expect less than 25 mL of secretions per day in the drainage devices<\/p>\n\n\n\n -I will keep my left arm flexed at the elbow as much as possible<\/p>\n\n\n\n -I will have to wait 2 months before additional saline can be added to my breast expander<\/p>\n\n\n\n 29. A nurse is caring for a client who has diabetes mellitus and has been following a treatment<\/p>\n\n\n\n plan for 3 months. Which of the following laboratory results should the nurse monitor to<\/p>\n\n\n\n determine long-term glycemic control?<\/p>\n\n\n\n -Oral glucose tolerance test results<\/p>\n\n\n\n -Fasting blood glucose level<\/p>\n\n\n\n -Glycosylated hemoglobin level<\/p>\n\n\n\n -Postprandial blood glucose level<\/p>\n\n\n\n 30. A nurse is providing discharge teaching to a client who has chronic urinary tract infections.<\/p>\n\n\n\n The client has a prescription for ciprofloxacin 250 mg PO twice daily. Which of the following<\/p>\n\n\n\n instructions should the nurse include in the teaching?<\/p>\n\n\n\n -Take a laxative to prevent constipation<\/p>\n\n\n\n -Drink 2 to 3 L of fluids daily<\/p>\n\n\n\n -Take an antacid 30 min before taking the medication<\/p>\n\n\n\n -Monitor heart rate once daily<\/p>\n\n\n\n 31. A nurse is providing teaching to a client who has a deep-vein thrombosis (DVT). Which of<\/p>\n\n\n\n the following findings should the nurse identify as a risk factor for the development of DVTs?<\/p>\n\n\n\n NSAID use<\/p>\n\n\n\n Cirrhosis<\/p>\n\n\n\n Hypertension<\/p>\n\n\n\n Oral contraceptive use<\/p>\n\n\n\n 32. A nurse is caring for client who has Cushing\u2019s disease. Which of the following actions<\/p>\n\n\n\n should the nurse take first? (Click on the Exhibit button below for additional information<\/p>\n\n\n\n about the client. There are three tabs that contain separate categories of data.)<\/p>\n\n\n\n -Auscultate the client\u2019s lung sounds<\/p>\n\n\n\n -Check the client\u2019s medication administration record for antihypertensive medications<\/p>\n\n\n\n -Determine the need for further glucose monitoring<\/p>\n\n\n\n -Verify the client\u2019s understanding of sodium restriction<\/p>\n\n\n\n 33. A nurse is assessing a client who has nephrotic syndrome. Which of the following findings<\/p>\n\n\n\n should the nurse expect?<\/p>\n\n\n\n -Proteinuria<\/p>\n\n\n\n -Hyperalbuminemia<\/p>\n\n\n\n -Flank pain<\/p>\n\n\n\n -Hypotension<\/p>\n\n\n\n 34. A nurse is preparing to administer a 250 mL IV bolus of dextrose 5% in water to infuse<\/p>\n\n\n\n over 2 hr. for a client. The drop factor is 10 gtt.\/mL. The nurse should set the pump to<\/p>\n\n\n\n administer how many gtt.\/min? (Round the answer to the nearest whole number. Use a leading<\/p>\n\n\n\n zero if it applies. Do not use a trailing zero.)<\/p>\n\n\n\n gtt.\/min (change 2 hours to minutes = 120 minutes)<\/p>\n\n\n\n 250 mL x 10 gtts\/mL = 21 gtts\/mL.<\/p>\n\n\n\n 120 mins.<\/p>\n\n\n\n 35. A nurse is assessing a client who has right-sided heart failure. Which of the following<\/p>\n\n\n\n assessment findings should the nurse expect to find?<\/p>\n\n\n\n -Poor skin turgor<\/p>\n\n\n\n -Pitting edema<\/p>\n\n\n\n -Oliguria<\/p>\n\n\n\n -S3\/S4 galloping heart sounds<\/p>\n\n\n\n 36. A nurse is caring for a client who has a newly inserted chest tube. The nurse should<\/p>\n\n\n\n clarify which of the following prescriptions with the provider?<\/p>\n\n\n\n -Administer morphine 2 mg IV bolus every 3 hr. PRN for pain<\/p>\n\n\n\n -Vigorously strip the chest tube twice daily<\/p>\n\n\n\n -Notify the provider when tidaling creases<\/p>\n\n\n\n -Assist the client out of bed 3 times daily<\/p>\n\n\n\n 37. A nurse is teaching a client who is taking an ACE inhibitor for heart failure. Which of<\/p>\n\n\n\n the following instructions should the nurse include for home management of heart failure?<\/p>\n\n\n\n -Limit daily activity<\/p>\n\n\n\n -Obtain daily weight<\/p>\n\n\n\n -Monitor intake and output<\/p>\n\n\n\n -Use a salt substitute<\/p>\n\n\n\n 38. A nurse is providing discharge teaching to a client who has a permanent pacemaker. Which<\/p>\n\n\n\n of the following statements by the client indicates an understanding of the teaching?<\/p>\n\n\n\n -I need to check my pulse rate every day for a full minute<\/p>\n\n\n\n -When a microwave oven I in use, I need to stay out of the room<\/p>\n\n\n\n -I need to maintain pressure over the pacemaker site with an elastic bandage<\/p>\n\n\n\n -The pacemaker will deliver a shock if I develop a dysrhythmia<\/p>\n\n\n\n 39. A nurse in a clinic is providing preventive teaching to an older adult client during a well visit.<\/p>\n\n\n\n The nurse should instruct the client that which of the followingimmunizations are<\/p>\n\n\n\n recommended for healthy adults after age 60? (Select all that apply.)<\/p>\n\n\n\n -Influenza<\/p>\n\n\n\n -Human Papillomavirus<\/p>\n\n\n\n -Meningococcal<\/p>\n\n\n\n -Herpes Zoster<\/p>\n\n\n\n -Pneumococcal polysaccharide<\/p>\n\n\n\n 40. A nurse is assessing a client who is 4 hr. postoperative following arterial revascularization<\/p>\n\n\n\n of the left femoral artery. Which of the following findings should the nurse repot to the<\/p>\n\n\n\n provider immediately?<\/p>\n\n\n\n -Urine output 150 mL over 4 hr.<\/p>\n\n\n\n -Pallor in the affected extremity<\/p>\n\n\n\n -Bruising around the incisional site<\/p>\n\n\n\n -Temperature of 37.9 C (100.2 F)<\/p>\n\n\n\n 41. A nurse is caring for an older adult who has not been eating. Which of the following<\/p>\n\n\n\n findings indicate dehydration?<\/p>\n\n\n\n -Capillary refill of 2 seconds<\/p>\n\n\n\n -Engorged neck veins<\/p>\n\n\n\n -Crackles auscultated bilaterally<\/p>\n\n\n\n -Diminished peripheral pulses (thready pulse)<\/p>\n\n\n\n 42. A nurse is preparing to discharge a client who has a halo device and is reviewing<\/p>\n\n\n\n prescriptions from the provider. The nurse should clarify which of the following<\/p>\n\n\n\n prescriptions with the provider?<\/p>\n\n\n\n -May place a small pillow under the head when sleeping<\/p>\n\n\n\n -Take tub baths instead of showers<\/p>\n\n\n\n -Increase intake of fiber-rich foods.<\/p>\n\n\n\n -May operate a motor vehicle when no longer taking analgesics<\/p>\n\n\n\n 43. A nurse is assessing for early signs of compartment syndrome for a client who has a short-<\/p>\n\n\n\n leg fiberglass cast. Which of the following findings should the nurse expect?<\/p>\n\n\n\n -Bounding distal pulses<\/p>\n\n\n\n -Intense pain with movement<\/p>\n\n\n\n -Capillary refill less than 2 seconds<\/p>\n\n\n\n -Erythema of the toes<\/p>\n\n\n\n 44. A nurse is caring for a client who is postoperative following coronary artery bypass surgery<\/p>\n\n\n\n and reports shortness of breath. The nurse administers oxygen at 3 L\/min and obtains arterial<\/p>\n\n\n\n blood gases 60 min later. Which of the following laboratory findings indicates a positive<\/p>\n\n\n\n response to the oxygen therapy?<\/p>\n\n\n\n -pH 7.32<\/p>\n\n\n\n -PaCO2 34 mm Hg<\/p>\n\n\n\n -Pa02 90 mm Hg<\/p>\n\n\n\n -Bicarbonate 20 mEq\/L<\/p>\n\n\n\n 45. A nurse is preforming a cranial nerve assessment on a client following a head injury. Which<\/p>\n\n\n\n of the following findings should the nurse expect if the client has impaired function of the<\/p>\n\n\n\n vestibulocochlear nerve (cranial nerve VIII)?<\/p>\n\n\n\n -Loss of peripheral vision<\/p>\n\n\n\n -Deviation of the tongue from midline<\/p>\n\n\n\n -Disequilibrium with movement<\/p>\n\n\n\n -Inability to smell<\/p>\n\n\n\n 46. A nurse is caring for a client admitted with a skull fracture. Which of the following<\/p>\n\n\n\n assessment findings should be of greatest concern to the nurse?<\/p>\n\n\n\n -Bilateral pupil diameter changes from 4 to 2 mm<\/p>\n\n\n\n -Glasgow Coma Scale score changes from 14 to 9<\/p>\n\n\n\n -Pulse pressure changes from 30 to 20 mm\/hg<\/p>\n\n\n\n -WBC count changes from 9,000 to 16,000\/mm3<\/p>\n\n\n\n 47. A nurse is caring for a client who presents to the emergency department after experiencing a<\/p>\n\n\n\n heat stroke. Which of the following actions should the nurse take?<\/p>\n\n\n\n -Administer an antipyretic<\/p>\n\n\n\n -Apply a cooling blanket<\/p>\n\n\n\n -Assess axillary temperature every 15 min.<\/p>\n\n\n\n -Administer lactated Ringer\u2019s<\/p>\n\n\n\n 48. A nurse is caring for a client who is taking furosemide. The client has a potassium level of<\/p>\n\n\n\n 3.1 mEq\/L. Which of the following should the nurse assess first?<\/p>\n\n\n\n -Muscle weakness<\/p>\n\n\n\n -Urine output<\/p>\n\n\n\n -Level of orientation<\/p>\n\n\n\n -Cardiovascular status<\/p>\n\n\n\n 49. A nurse is caring for a client who is scheduled for an abdominal paracentesis. The nurse<\/p>\n\n\n\n should plan to take which of the following actions?<\/p>\n\n\n\n -Administer a stool softener following the procedure<\/p>\n\n\n\n -Instruct the client to take deep breaths and hold them during the procedure<\/p>\n\n\n\n -Assist the client into the left lateral position during the procedure<\/p>\n\n\n\n -Ask the client to empty his bladder prior to the procedure<\/p>\n\n\n\n 50. A nurse is caring for a client who is 6 hr. postoperative following a thyroidectomy. The client<\/p>\n\n\n\n reports tingling andnumbness in the hands. The nurse should identify this as a sign of which of<\/p>\n\n\n\n the following electrolyte imbalances?<\/p>\n\n\n\n -Hypernatremia<\/p>\n\n\n\n -Hypocalcemia<\/p>\n\n\n\n -Hypermagnesemia<\/p>\n\n\n\n -Hypokalemia<\/p>\n\n\n\n 51. A nurse is assessing a client 15 min after the start of a transfusion of 1 unit of packed RBCs.<\/p>\n\n\n\n Which of the following findings is an indication of a hemolytic transfusion reaction?<\/p>\n\n\n\n -Hypotension<\/p>\n\n\n\n -Hypothermia<\/p>\n\n\n\n -Bradypnea<\/p>\n\n\n\n -Bradycardia<\/p>\n\n\n\n 52. A nurse in an emergency department is caring for a client who has sinus bradycardia. Which<\/p>\n\n\n\n of the following actions should the nurse take first?<\/p>\n\n\n\n -Administer atropine to the client<\/p>\n\n\n\n -Initiate IV therapy for the client<\/p>\n\n\n\n -Measure the client\u2019s blood pressure<\/p>\n\n\n\n -Prepare the client for temporary pacing<\/p>\n\n\n\n 53. A nurse is caring for a client who has a prescription to discontinue a peripherally inserted<\/p>\n\n\n\n central catheter. Which of the following should the nurse take?<\/p>\n\n\n\n -Place a dry sterile dressing to the site after removal<\/p>\n\n\n\n -Measure the catheter after removal<\/p>\n\n\n\n -Apply slight pressure when resistance is met<\/p>\n\n\n\n -Remove the catheter with one continuous motion<\/p>\n\n\n\n 54. A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes<\/p>\n\n\n\n that the weights are resting on the floor. Which of the following actions should the nurse take?<\/p>\n\n\n\n -Remove one of the weights<\/p>\n\n\n\n -Increase the elevation of the effected extremity<\/p>\n\n\n\n -Pull the client up in bed<\/p>\n\n\n\n -Tie knots in the ropes near the pulleys to shorten them<\/p>\n\n\n\n 55. A nurse is caring for a client who has a flail chest. Which of the following actions should the<\/p>\n\n\n\n nurse take?<\/p>\n\n\n\n -Implement fluid restriction<\/p>\n\n\n\n -Administer antibiotic medication<\/p>\n\n\n\n -Administer acetaminophen orally<\/p>\n\n\n\n -Provide humidified oxygen<\/p>\n\n\n\n 56. A nurse is teaching a group of newly licensed nurses about acute respiratory failure. Which<\/p>\n\n\n\n of the following manifestations should the nurse include in the teaching?<\/p>\n\n\n\n -Hypocarbia<\/p>\n\n\n\n -Hypoxemia<\/p>\n\n\n\n -Hyperventilation<\/p>\n\n\n\n -Hypovolemia<\/p>\n\n\n\n 57. A nurse is caring for a client who is experiencing a seizure. Which of the following actions<\/p>\n\n\n\n should the nurse take first?<\/p>\n\n\n\n -Clear items from the client\u2019s surrounding area.<\/p>\n\n\n\n -Obtain the client\u2019s vital signs<\/p>\n\n\n\n -Loosen the client\u2019s restrictive clothing<\/p>\n\n\n\n -Lower the client to the floor<\/p>\n\n\n\n 58. A nurse is teaching a client who is receiving total parenteral nutrition at home through a<\/p>\n\n\n\n central venous access device about transparent dressing changes. Which of the following<\/p>\n\n\n\n instructions should the nurse include in the teaching?<\/p>\n\n\n\n -Use clean technique when changing the dressing<\/p>\n\n\n\n -Wear a mask during the dressing change<\/p>\n\n\n\n -Replace the extension tubing with each dressing change<\/p>\n\n\n\n -Change the dressing every 48hr.<\/p>\n\n\n\n 59. A nurse is caring for a client in the emergency department who experienced a full-<\/p>\n\n\n\n thickness burn injury to the lower torso 1 hour ago. Which of the following findings should<\/p>\n\n\n\n the nurse expect?<\/p>\n\n\n\n -Decreased respiratory rate<\/p>\n\n\n\n -Urinary diuresis<\/p>\n\n\n\n -Hypotension<\/p>\n\n\n\n -Bradycardia<\/p>\n\n\n\n 60. A nurse in an emergency department is assessing a client who has cirrhosis of the liver.<\/p>\n\n\n\n Which of the following is a priority finding?<\/p>\n\n\n\n -Yellow sclera<\/p>\n\n\n\n -Mental confusion<\/p>\n\n\n\n -Palmar erythema<\/p>\n\n\n\n -Spider angiomas<\/p>\n\n\n\n 61. A nurse is providing instructions about foot care for a client who has peripheral arterial<\/p>\n\n\n\n disease. The nurse should identify that which of the following statements by the client<\/p>\n\n\n\n indicates an understanding of the teaching?<\/p>\n\n\n\n -I apply a lubricating lotion to the cracked areas on the soles of my feet every morning<\/p>\n\n\n\n -I use my heating pad on a low setting to keep my feet warm<\/p>\n\n\n\n -I soak my feet in hot water before trimming my toenails<\/p>\n\n\n\n -I rest in my recliner with my feet elevated for about an hour every afternoon<\/p>\n\n\n\n 62. A nurse is teaching a client who has a new prescription for (alendronate to treat)<\/p>\n\n\n\n osteoporosis. Which of the following instructions should the nurse include in the<\/p>\n\n\n\n teaching?<\/p>\n\n\n\n -Swallow the medication with 120 mL (4oz) of water<\/p>\n\n\n\n -Sit upright for 30 min. after taking the medication<\/p>\n\n\n\n -Take the medication with lunch<\/p>\n\n\n\n -Take the medication with a vitamin E supplement<\/p>\n\n\n\n 63. A nurse is teaching a client about using a metered-dose rescue inhaler. Which of the follow<\/p>\n\n\n\n statement should the nurse include in the teaching?<\/p>\n\n\n\n -Exhale fully before bringing the inhaler to your lips<\/p>\n\n\n\n -Do not shake your inhaler before use<\/p>\n\n\n\n -Use peroxide to clean the mouthpiece of your inhaler<\/p>\n\n\n\n -Depress the canister after you exhale<\/p>\n\n\n\n 64. A nurse is admitting a client to the emergency department after a gunshot wound to the<\/p>\n\n\n\n abdomen. Which of the following actions should the nurse take to help prevent the onset of<\/p>\n\n\n\n acute kidney failure?<\/p>\n\n\n\n -Imitate beta blocker therapy<\/p>\n\n\n\n -Administer IV fluids to the client<\/p>\n\n\n\n -Insert a urinary catheter<\/p>\n\n\n\n -Prepare the client for an intravenous pyelogram<\/p>\n\n\n\n 65. A nurse is completing an assessment of an older adult client and notes reddened areas over<\/p>\n\n\n\n the bony prominences, but the client\u2019s skin is intact. Which of the following interventions<\/p>\n\n\n\n should the nurse include in the plan of care?<\/p>\n\n\n\n -Massage the reddened areas three times daily<\/p>\n\n\n\n -Turn and reposition the client every 4 hr.<\/p>\n\n\n\n -Support bony prominences with pillows<\/p>\n\n\n\n -Apply an occlusive dressing<\/p>\n\n\n\n 66. A nurse is reviewing the medical record of a client who is to undergo open heart surgery.<\/p>\n\n\n\n Which of the following findings should the nurse report to the provider as a contraindication to<\/p>\n\n\n\n receive heparin?<\/p>\n\n\n\n -Thrombocytopenia<\/p>\n\n\n\n -COPD<\/p>\n\n\n\n -Thalassemia<\/p>\n\n\n\n -Rheumatoid arthritis<\/p>\n\n\n\n 67. A nurse is caring for a client who as completed 10 daily cycles of total parenteral nutrition<\/p>\n\n\n\n (TPN). Which of the following findings indicates that the client is receiving adequate TPN<\/p>\n\n\n\n supplementation?<\/p>\n\n\n\n -Weight gain of 9.1 kg (20 lb.)<\/p>\n\n\n\n -BUN level of 15 mg\/dL<\/p>\n\n\n\n -Improved mobility<\/p>\n\n\n\n -Potassium level of 2.5 mEq\/L<\/p>\n\n\n\n 68. A nurse is providing teaching to a client who is postoperative following a partial<\/p>\n\n\n\n glossectomy. Which of the following statements by the client indicates an understanding of the<\/p>\n\n\n\n teaching?<\/p>\n\n\n\n -I will inspect my mouth once each week for sores<\/p>\n\n\n\n -I will drink orange juice to increase my vitamin C intake<\/p>\n\n\n\n -I will consume canned soap whenever sores appear in my mouth<\/p>\n\n\n\n -I will rinse my toothbrush with hydrogen peroxide and water after each use<\/p>\n\n\n\n 69. A nurse is preforming an ear irrigation for a client. Which of the following actions should the<\/p>\n\n\n\n nurse take?<\/p>\n\n\n\n -Use cool fluid for irrigation<\/p>\n\n\n\n -Insert the tip of the syringe 2.5 cm (1 in) into the ear canal<\/p>\n\n\n\n -Tilt the client\u2019s head 45 degrees<\/p>\n\n\n\n -Point the tip of the syringe toward the top of the ear canal<\/p>\n\n\n\n 70. A nurse is caring for a client who is receiving continuous bladder irrigation following a<\/p>\n\n\n\n transurethral resection of the prostate (TURP). The client reports sharp lower abdominal<\/p>\n\n\n\n pain. Which of the following actions should the nurse take first?<\/p>\n\n\n\n -Administer PRN pain medication<\/p>\n\n\n\n -Check the client\u2019s urine output<\/p>\n\n\n\n -Reposition the client in bed<\/p>\n\n\n\n Increase the client\u2019s fluid intake<\/p>\n\n\n\n 71. A nurse is providing teaching for a client who has diabetes mellitus about the self-<\/p>\n\n\n\n administration of insulin. The client has prescriptions for regular and NPH insulins. Which<\/p>\n\n\n\n of the following statements by the client indicates an understanding of the teaching?<\/p>\n\n\n\n -I will store prefilled syringes in the refrigerator with the needle pointed downward<\/p>\n\n\n\n -I will shake the NPH vial vigorously before drawing up the insulin<\/p>\n\n\n\n -I will draw up the regular insulin into the syringe first (clear before cloudy)<\/p>\n\n\n\n -I will insert the needle at a 15-degree angle<\/p>\n\n\n\n 72. A nurse is caring for a client who has systemic lupus erythematous. During assessment,<\/p>\n\n\n\n which of the following should the nurse expect to find?<\/p>\n\n\n\n -Esophagitis<\/p>\n\n\n\n -Tophi<\/p>\n\n\n\n -Bull eye lesions<\/p>\n\n\n\n -Joint inflammation<\/p>\n\n\n\n 73. A nurse is monitoring an older adult client who has an exacerbation of chronic<\/p>\n\n\n\n lymphocytic leukemia. The nurse notes petechiae on the client\u2019s skin.<\/p>\n\n\n\n -Institute bleeding precautions<\/p>\n\n\n\n -Determine the client\u2019s blood type<\/p>\n\n\n\n -Avoid administering IV pain medication<\/p>\n\n\n\n -Implement airborne precautions<\/p>\n\n\n\n 74. A nurse is caring for a client who is receiving TPN nutrition (TPN). Which of the following<\/p>\n\n\n\n actions are appropriate? (Select all that apply.)<\/p>\n\n\n\n Increase the rate of infusion if administration is delayed<\/p>\n\n\n\n Monitor serum blood glucose during infusion<\/p>\n\n\n\n Infuse 0.9% sodium chloride if the solution is not available<\/p>\n\n\n\n Verify the solution with another RN prior to infusion<\/p>\n\n\n\n Obtain the client\u2019s daily weight<\/p>\n\n\n\n 75. A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the<\/p>\n\n\n\n priority intervention by the nurse?<\/p>\n\n\n\n -Begin bicarbonate continuous IV infusion<\/p>\n\n\n\n -Administer 0.9% sodium chloride<\/p>\n\n\n\n -Check potassium levels<\/p>\n\n\n\n -Initiate a continuous IV insulin infusion<\/p>\n\n\n\n 76. A nurse is reviewing the laboratory results of a female client who ask about acupuncture as<\/p>\n\n\n\n treatment for chemotherapy-induced nausea and vomiting. Which of the following<\/p>\n\n\n\n laboratory results should the nurse identify as a contraindication to receiving acupuncture?<\/p>\n\n\n\n Hemoglobin 12 g\/dL<\/p>\n\n\n\n C-reactive protein 0.7 mg\/dL<\/p>\n\n\n\n Platelets 160,000\/mm3<\/p>\n\n\n\n Absolute neutrophil count 500\/mm3<\/p>\n\n\n\n 77. A nurse is caring for a client following a total knee arthroplasty. The client reports a pain<\/p>\n\n\n\n level of 6 on a pain scale of 0 to 10. Which of the following interventions should the nurse<\/p>\n\n\n\n take?<\/p>\n\n\n\n -Gently massage the area around the client\u2019s incision<\/p>\n\n\n\n -Apply an ice pack to the client\u2019s knee<\/p>\n\n\n\n -Perform range of motion exercises to the client\u2019s knee<\/p>\n\n\n\n -Place pillows under the client\u2019s knee<\/p>\n\n\n\n 78. A nurse is assessing a client who has heart failure and is receiving a loop diuretic. Which of<\/p>\n\n\n\n the following findings indicates hypokalemia?<\/p>\n\n\n\n -Muscle weakness<\/p>\n\n\n\n -Hypertension<\/p>\n\n\n\n -Positive chvostek sign<\/p>\n\n\n\n -Oliguria<\/p>\n\n\n\n 79. A nurse at a long-term facility is assessing an older adult client. Which of the following<\/p>\n\n\n\n findings should the nurse identify as an indication that the client has a recall memory<\/p>\n\n\n\n impairment?<\/p>\n\n\n\n -Inability to state his current age<\/p>\n\n\n\n -Inability to name the members of his family<\/p>\n\n\n\n -Inability to count backwards from 10<\/p>\n\n\n\n -Inability to state what he had for dinner last night<\/p>\n\n\n\n 80. A nurse on an intensive care unit is planning care for a client who has increased intra<\/p>\n\n\n\n cranial pressure following a head injury. Which of the following IV medications should<\/p>\n\n\n\n the nurse plan to administer?<\/p>\n\n\n\n -Chlorpromazine<\/p>\n\n\n\n -Mannitol<\/p>\n\n\n\n -Dobutamine<\/p>\n\n\n\n -Propranolol<\/p>\n\n\n\n 81. A nurse on a medical unit is planning care for a group of clients. Which of the following<\/p>\n\n\n\n clients should the nurse see first?<\/p>\n\n\n\n -A client who has left-sided paralysis and slurred speech from a prior stroke<\/p>\n\n\n\n -A client who has multiple sclerosis and reports ataxia and vertigo<\/p>\n\n\n\n -A client who has thrombocytopenia and reports a nosebleed<\/p>\n\n\n\n -A client who has chronic obstruction pulmonary disease and an oxygen saturation of 89%<\/p>\n\n\n\n 82. A home care nurse is planning to use nonpharmacological pain relief measures for an older<\/p>\n\n\n\n adult who has sever chronic back pain. Which of the following guidelines should the nurse use?<\/p>\n\n\n\n Discontinue opioids before trying nonpharmacological methods of pain relief<\/p>\n\n\n\n Pain relief from the use of heat and cold continues for several hours after removal of the stimulus<\/p>\n\n\n\n Use imagery with clients who have difficulty with focus and concentration<\/p>\n\n\n\n Distraction changes the client\u2019s perception of pain, but does not affect the cause<\/p>\n\n\n\n 83. A nurse is providing teaching to a client who is to start furosemide therapy for heart failure.<\/p>\n\n\n\n Which of the following statements indicates that the client understands a potential adverse<\/p>\n\n\n\n effect of this medication?<\/p>\n\n\n\n -I\u2019m going to include more cantaloupe in my diet<\/p>\n\n\n\n -I will try to limit foods that contain salt<\/p>\n\n\n\n -I will check my pulse before I take the medication<\/p>\n\n\n\n -I\u2019ll check my blood pressure, so it doesn\u2019t get too high<\/p>\n\n\n\n 84. A nurse is providing discharge teaching for a client who has HIV. Which of the following<\/p>\n\n\n\n information is the priority for the nurse to review with the client?<\/p>\n\n\n\n -Describe your daily medication schedule<\/p>\n\n\n\n -Name a few things you will change about your diet<\/p>\n\n\n\n -List some ways you can cope with the stress of your illness<\/p>\n\n\n\n -Tell me why it\u2019s important to have your CD4+ count checked<\/p>\n\n\n\n 85. A nurse is caring for a client who has an endotracheal tube. Which of the following actions<\/p>\n\n\n\n should the nurse take to verify the tube placement?<\/p>\n\n\n\n -Deflate the cuff to check for tube placement<\/p>\n\n\n\n -Place the clients head and neck in a flexed position<\/p>\n\n\n\n -Document the tube length where it passes the chin<\/p>\n\n\n\n -Observe for symmetry of chest expansion<\/p>\n\n\n\n 86. A nurse in an emergency department is caring for a client who is receiving treatment for<\/p>\n\n\n\n excessive ingestion of antacids. The nurse should identify that this client is at risk for which<\/p>\n\n\n\n of the following acid-base imbalances?<\/p>\n\n\n\n -Metabolic acidosis<\/p>\n\n\n\n -Respiratory acidosis<\/p>\n\n\n\n -Respiratory alkalosis<\/p>\n\n\n\n -Metabolic alkalosis<\/p>\n\n\n\n 87. A nurse is assessing a client for a positive Chvostek\u2019s sign following a thyroidectomy. Which<\/p>\n\n\n\n of the following areas on the client\u2019s head should the nurse tap to assess the client for tetany?<\/p>\n\n\n\n (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds<\/p>\n\n\n\n to your answer.) (The cheek area)<\/p>\n\n\n\n 88. A nurse is caring for a client who has advance liver disease. Which of the following<\/p>\n\n\n\n laboratory results should the nurse monitor when assessing this client?<\/p>\n\n\n\n -Phosphate level<\/p>\n\n\n\n -Serum troponin<\/p>\n\n\n\n -Serum ammonia<\/p>\n\n\n\n -Glucose level<\/p>\n\n\n\n 89. A nurse is caring for a client who has a pneumothorax and a chest tube with the closed<\/p>\n\n\n\n water-seal drainage system. Which of the following actions should the nurse take?<\/p>\n\n\n\n -Strip or clear the chest tube every 8 hours<\/p>\n\n\n\n -Change the chest tube site dressing every 24 hr.<\/p>\n\n\n\n -Empty the system at least every 8 hours<\/p>\n\n\n\n -Refill the water chamber if the fluid level is low<\/p>\n\n\n\n 90. a nurse in an emergency department is reviewing a client\u2019s ECG reading. Which of the<\/p>\n\n\n\n following finding should the nurse identify as an indication that the client has first-degree heart<\/p>\n\n\n\n block?<\/p>\n\n\n\n -Prolonged PR intervals<\/p>\n\n\n\n -More P waves than QRS complexes<\/p>\n\n\n\n -Non discernible P waves<\/p>\n\n\n\n -No correlation between P and QRS waves<\/p>\n\n\n\n 91. A nurse is preparing to administer a unit of packed RBCs to a client who is anemic. Identify<\/p>\n\n\n\n a sequence of steps the nurse should follow. (Move the steps into the box on the right, placing<\/p>\n\n\n\n them in order of performance. Use all the steps.)<\/p>\n\n\n\n Correct Order<\/p>\n\n\n\n Verify blood compatibility with another nurse Obtain venous assess using a 19-gauge<\/p>\n\n\n\n needle<\/p>\n\n\n\n Remain with the client for the first 15 to 30<\/p>\n\n\n\n minutes of the infusion<\/p>\n\n\n\n Obtain the unit of packed RBCs from the<\/p>\n\n\n\n blood bank<\/p>\n\n\n\n Obtain the unit of packed RBCs from the<\/p>\n\n\n\n blood bank<\/p>\n\n\n\n Verify blood compatibility with another<\/p>\n\n\n\n nurse<\/p>\n\n\n\n Initiate transfusion of the unit of packed<\/p>\n\n\n\n RBCs<\/p>\n\n\n\n Initiate transfusion of the unit of packed<\/p>\n\n\n\n RBCs<\/p>\n\n\n\n Obtain venous assess using a 19-gauge needle Remain with the client for the first 15 to 30<\/p>\n\n\n\n minutes of the infusion<\/p>\n\n\n\n 92. A nurse is teaching a client who is to begin chemotherapy about a peripherally inserted<\/p>\n\n\n\n central catheter (PICC). Which of the following statement should the nurse include in the<\/p>\n\n\n\n teaching?<\/p>\n\n\n\n -We can draw blood samples from the PICC for diagnostics test<\/p>\n\n\n\n -We will replace the PICC every month<\/p>\n\n\n\n -We will change the dressing daily<\/p>\n\n\n\n -We can measure your blood pressure in either arm<\/p>\n\n\n\n 93. A nurse is assessing a client who has pyelonephritis and reports flank pain. Which of the<\/p>\n\n\n\n following actions should the nurse take?<\/p>\n\n\n\n -Auscultate for a bruit over the costovertebral area.<\/p>\n\n\n\n -Assist the client to a sitting position<\/p>\n\n\n\n -Thump the area of tenderness directly with a closed fist<\/p>\n\n\n\n -Percuss the side of tenderness first<\/p>\n\n\n\n 94. A nurse is assessing a client who has acute kidney injury failure. Which of the following<\/p>\n\n\n\n findings should the nurse report to the provider?<\/p>\n\n\n\n -Peripheral pulses 2+ bilaterally<\/p>\n\n\n\n -Creatinine 0.8 mL\/dL<\/p>\n\n\n\n -Urine specific gravity 1.045<\/p>\n\n\n\n -Weight gain 1.1 kg (2.4 lb.) in 24 hr.<\/p>\n\n\n\n 95. A nurse is caring for an older adult client who is 72 hr. postoperative following a total hip<\/p>\n\n\n\n arthroplasty. The client requires a PRN medication prior to ambulation. Which of the<\/p>\n\n\n\n following medications should the nurse anticipate administering?<\/p>\n\n\n\n -Naproxen<\/p>\n\n\n\n -Meperidine<\/p>\n\n\n\n -Indomethacin<\/p>\n\n\n\n -Oxycodone<\/p>\n\n\n\n 96. A nurse is providing discharge teaching to a client who has an impaired immune system due to<\/p>\n\n\n\n chemotherapy. Which of the following information should the nurse include in the teaching?<\/p>\n\n\n\n -Change your pet\u2019s litter box daily<\/p>\n\n\n\n -Wash your perineal area two times each day with antimicrobial soap<\/p>\n\n\n\n -Change the water in your drinking glass every 4 hours<\/p>\n\n\n\n -Wash your toothbrush in the dishwasher once a month<\/p>\n\n\n\n 97. A nurse is caring for a client who has Haemophiles influenza type B. Which of the following<\/p>\n\n\n\n types of isolation should the nurse implement?<\/p>\n\n\n\n -Droplet<\/p>\n\n\n\n -Airborne<\/p>\n\n\n\n -Protective<\/p>\n\n\n\n -Contact<\/p>\n\n\n\n 98. A nurse is providing discharge teaching to a client who has pulmonary tuberculosis. Which of<\/p>\n\n\n\n the following finding should the nurse include as an indication the client is no longer infectious?<\/p>\n\n\n\n -Negative sputum cultures for acid-fast bacillus<\/p>\n\n\n\n -Positive QuantiFERON-TB Gold test<\/p>\n\n\n\n -Mantoux skin test revealing an induration of less than 1 mm<\/p>\n\n\n\n -Client no longer coughing up blood-tinged sputum<\/p>\n\n\n\n 99. A nurse is working in the emergency department is caring for a client who has a burn injury.<\/p>\n\n\n\n After securing the client\u2019s airway, which of the following interventions should the nurse take<\/p>\n\n\n\n first?<\/p>\n\n\n\n -Cleanse the client\u2019s wounds<\/p>\n\n\n\n -Administer analgesic medication<\/p>\n\n\n\n -Start an IV with a large-bore needle<\/p>\n\n\n\n -Increase the room temperature<\/p>\n\n\n\n 100. A nurse is caring for a client who has a central venous access device and notes the tubing<\/p>\n\n\n\n has become disconnected. The client develops dyspnea and tachycardia. Which of the following<\/p>\n\n\n\n actions should the nurse take first?<\/p>\n\n\n\n -Obtain ABG values<\/p>\n\n\n\n -Perform an ECG<\/p>\n\n\n\n -Turn the client to his left side<\/p>\n\n\n\n -Clamp the catheter<\/p>\n","protected":false},"excerpt":{"rendered":" ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED + 1\u2026.A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client’s spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate? Large incisions […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[],"tags":[],"class_list":["post-110964","post","type-post","status-publish","format-standard","hentry"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/110964","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/comments?post=110964"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/110964\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=110964"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=110964"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=110964"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}\n
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