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ATI RN Adult Medical Surgical Online Practice 2019 A with Rationales

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a nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. the client is experiencing excessive stools. which of the following findings is an adverse effect of... the medication? (ANS- hypokalemia Lactulose works by stimulating the production of excess stools to rid the body of excess ammonia. These excessive stools can result in hypokalemia and dehydration. a nurse is caring for a client who has emphysema and is receiving mechanical ventilation. the client appears anxious and restless, and the high-pressure alarm is sounding. which of the following actions should the nurse take first? (ANS- instruct the client to allow the machine to breathe for them. When providing client care, the nurse should first use the least restrictive intervention. Therefore, the first action the nurse should take is to provide verbal instructions and emotional support to help the client relax and allow the ventilator to work. Clients can exhibit anxiety and restlessness when trying to "fight the ventilator." a nurse is teaching a client who has a family history of colorectal cancer. to help mitigate this risk, which of the following dietary alterations should the nurse recommend? (ANS- add cabbage to the diet. To help reduce the risk for colorectal cancer, the client should consume a diet that is high in fiber, low in fat, and low in refined carbohydrates. Brassica vegetables, such as cabbage, cauliflower, and broccoli, are high in fiber. a home health nurse is assigned to a client who was recently discharged from a rehabilitation center after experiencing a right-hemispheric stroke. which of the following neurological deficits should the nurse expect to find when assessing the client? (ANS- visual spatial deficits left hemianopsia one-sided neglect a nurse is caring for a client who has viral pneumonia. the client's pulse oximeter readings have fluctuated between 79% and 88% for the last 30 min. which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen? (ANS- nonrebreather mask The nurse should initiate a nonrebreather mask to deliver between 80% to 95% oxygen to the client. A client who has an unstable respiratory status should receive oxygen via a nonrebreather mask. a nurse is caring for a client who has bilateral pneumonia and an SaO2 of 85%. the client has dyspnea with a productive cough and is using accessory muscles to breathe. which of the following actions should the nurse take first? (ANS- place the client in high-fowler's position. The greatest risk to this client is injury from airway obstruction. Therefore, the priority intervention the nurse should take is to move the client into high-Fowler's position. High-Fowler's position facilitates lung expansion and improves ventilation and gas exchange. a nurse is planning care for a client who has extensive burn injuries and is immunocompromised. which of the following precautions should the nurse include in the plan of care to prevent a Pseudomonas aeruginosa infection. (ANS- avoid placing plants or flowers in the client's room. Live plants can harbor P. aeruginosa, and this bacterium can infect burn wounds and cause life-threatening complications. The nurse should ensure no one brings live plants or flowers into the client's room. an older adult client is brought to an emergency department by a family member. which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration? (ANS- Urine specific gravity of 1.045 A urine specific gravity greater than 1.030 indicates a decrease in urine volume and an increase in osmolarity, which is a manifestation of hypertonic dehydration. a nurse in an emergency department is reviewing the providers prescriptions for a client who sustained a rattlesnake bite to the lower leg. which of the following prescriptions should the nurse expect? (ANS- administer an opioid analgesic to the client. The nurse should expect a prescription for an opioid analgesic to promote comfort following a rattlesnake bite. a nurse is assessing a client who has had a suspected stroke. the nurse should place the priority on which of the following findings? (ANS- dysphagia Dysphagia indicates that this client is at greatest risk for aspiration due to impaired sensation and function within the oral cavity. Therefore, the nurse should place priority on this finding. a nurse is teaching a young adult client how to perform testicular self-examination. which of the following instructions should the nurse include? (ANS- roll each testicle between the thumb and fingers. The nurse should instruct the client to roll each testicle horizontally between the thumbs and fingers to feel for any lumps deep in the center of the testicle. [Show More]

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