ATI Med Surg Practice A 2020-2022. Questions with answers. Graded A+

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ATI Med Surg Practice A 2020-2022. Questions with answers. Graded A+ A nurse is reinforcing teaching with a client who has mitral valve disease. Which of following statements by the client indica... tes an understanding of the disease process? A. "I should call my doctor if I get a headache." B. "I might develop gastric reflux." C. "I might develop excessive bruising." D. "I should call my doctor if my ankles swell." - ✔✔D. "I should call my doctor if my ankles swell." RAT: Swelling of the ankles can indicate heart failure. The client should report this finding to the provider. A provider might prescribe anticoagulants to prevent thrombus formation on the valve, which can cause excessive bruising for a client who has mitral valve disease. However, excessive bruising is not a direct result of the disease. A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis. Which of the following information should the nurse include in the teaching? A. Apply cold packs to the inflamed joints. B. Participate in high-impact exercise. C. Carry a hand purse rather than a shoulder bag. D. Sleep on a soft foam mattress. - ✔✔A. Apply cold packs to the inflamed joints. RAT: The nurse should instruct the client to use both warm and cold packs on inflamed joints to decrease pain. A nurse is collecting data from who has hypothyroidism. Which of the following manifestations should the nurse anticipate? A. Blurred vision B. Insomnia C. Bradycardia D. Weight loss - ✔✔C. Bradycardia RAT: The nurse should identify that bradycardia is a manifestation of hypothyroidism that is caused by a decrease in the client's metabolic rate. A nurse is reinforcing teaching with an adolescent child regarding testicular self-examination. Which of the following statements by the client indicates an understanding of the teaching? A. "I will perform the exam before I shower." B. "I will check my testicles every 6 months." C. "I understand that testicular cancer is typically painless." D. "I understand that pea-sized lumps are normal." - ✔✔C. "I understand that testicular cancer is typically painless." RAT: Clients should report a lump that is not painful because testicular cancer is typically painless. Clients should perform a testicular self-examination after a warm shower. Clients should perform a testicular self-examination monthly. A nurse is contributing to the plan of care of a client who is at risk for osteoporosis. Which of the following interventions should the nurse include to prevent bone loss? A. Increase fluid intake. B. Encourage range-of-motion exercises. C. Massage bony prominences. D. Encourage weight-bearing exercises. - ✔✔D. Encourage weight-bearing exercises. Weight-bearing exercises, such as walking, can maintain bone mass by reducing bone demineralization, thus helping to prevent osteoporosis. A nurse is reinforcing teaching about management of constipation with a client who has hypothyroidism. Which of the following instructions should the nurse include in the teaching? A. Increase intake of fiber-rich foods. B. Take a laxative every morning. C. Maintain a fluid intake of 1,200 mL/day. D. Limit activity to preserve energy. - ✔✔A. Increase intake of fiber-rich foods. RAT: The nurse should instruct the client to increase the amount of fiber-rich foods in their diet. Dried beans and brown rice are examples of fiber-rich foods. The nurse should instruct the client to increase activity to stimulate the evacuation of stool. A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. Which of the following statements indicates that the client is adhering to the nurse's instructions? A. "I apply rubbing alcohol to my feet every day to prevent infection." B. "I will wear clean, knee-high wool socks every day to help improve my circulation." C. "I use hot water bottles to keep my feet warm at night." D. "I don't cross my legs anymore." - ✔✔D. "I don't cross my legs anymore." RAT: Clients who have peripheral vascular disease should not cross their legs because it can impede circulation. A nurse observes a client who is lying in bed and experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? A. Lower the side rails of the client's bed. B. Apply wrist restraints to the client. C. Position the client in the semi-Fowler's position. D. Loosen clothing around the client's neck. - ✔✔D. Loosen clothing around the client's neck. RAT: The nurse should loosen clothing around the client's neck to maintain an open airway and prevent aspiration. A nurse is reinforcing teaching with the caregiver of a client who is terminally ill about manifestations of impending death. Which of the following manifestations should the nurse include? A. Incontinence of bowel and bladder B. Increase in heart rate C. Warmness of the skin D. Hypertension - ✔✔A. Incontinence of bowel and bladder RAT: The nurse should inform the caregiver that incontinence of the bowel and bladder is a manifestation of impending death. Other manifestations include hypotension, bradycardia, restlessness, and coolness of the skin. A nurse in an oncology clinic is reinforcing teaching about Mohs surgery with a client who has skin cancer. Which of the following information should the nurse include in the teaching? A. Mohs surgery is a horizontal shaving of thin layers of the tumor. Mohs surgery uses liquid nitrogen to destroy the cancerous tissue. Mohs surgery is the preferred treatment for melanoma skin cancer. Mohs surgery is a palliative treatment for metastatic skin cancer. - ✔✔A. Mohs surgery is a horizontal shaving of thin layers of the tumor. RAT: Mohs surgery is performed to treat basal and squamous cell carcinoma. The procedure, which involves a horizontal shaving of thin layers of a tumor, has a high success rate. A nurse is assisting in the plan of care for a client who has had a recent left hemispheric stroke. Which of the following actions should the nurse include in the plan? Observe for impulsive behavior. Approach the client from the right side. Use simple verbal cues when directing tasks. Place the client in low-Fowler's position during meals. - ✔✔Use simple verbal cues when directing tasks. RAT: The nurse should expect a client who had a left hemispheric stroke to manifest some degree of expressive and/or receptive aphasia. Using simple verbal cues will assist the client in understanding spoken communication. A nurse is caring for a client who reports stomatitis. Which of the following dietary recommendations should the nurse make? "Eat soft foods." "Season foods with salt." "Select foods that are low in protein." "Choose foods that are served hot." - ✔✔"Eat soft foods." RAT: The nurse should instruct a client who has stomatitis to eat soft, nonirritating foods to decrease irritation to the oral mucosa. A nurse is reviewing the laboratory result of a client who has chronic kidney failure and is receiving epoetin alfa. The nurse should identify that which of the following laboratory values indicates the treatment is effective? BUN 40 mg/dL Hgb 11 g/dL Urine specific gravity 1.035 Blood glucose 105 mg/dL - ✔✔Hgb 11 g/dL RAT: Epoetin alfa stimulates the production of erythropoietin and red blood cells, resulting in increased hemoglobin levels. Therefore, a hemoglobin level of 11 g/dL indicates the epoetin alfa treatment is effective. A nurse assisting in the care of a client who has manifestations of sepsis. Which of the following provider prescriptions should the nurse implement first? Collect a sputum culture. Administer ceftriaxone by intermittent IV bolus. Initiate oxygen at 4 L/min via nasal cannula. Obtain blood cultures. - ✔✔Initiate oxygen at 4 L/min via nasal cannula. RAT: When using the airway, breathing, circulation approach to client care, the first action the nurse should take is to initiate oxygen. Clients who have manifestations of sepsis are often hypoxic, tachypneic, or have a PaCO2 level less than 32 mm Hg. The nurse should provide supplemental oxygen to keep the client's oxygen saturation levels at 95% or greater, which will maximize the ability of the hemoglobin to support the oxygen needs of the body. A nurse is reinforcing teaching with a client who is scheduled for a guaiac fecal occult blood test. Which of the following instructions should the nurse include in the teaching? Do not eat or drink for 6 hr prior to the test. Ensure that the stool specimen is obtained in the morning. Take ibuprofen for mild pain until the test is complete. Avoid eating red meat for 3 days prior to the test. - ✔✔Avoid eating red meat for 3 days prior to the test. RAT: The nurse should instruct the client to avoid eating red meat for 3 days prior to the guaiac fecal occult blood test because this can lead to a false positive result. A nurse is reinforcing discharge teaching with a client who has cirrhosis. Which of the following instructions should the nurse include ? "You can take acetaminophen for pain." "Consume a diet that is high in animal protein." "Sleep lying flat on your back." "Consume foods that are low in sodium." - ✔✔"Consume foods that are low in sodium." RAT: The nurse should instruct the client to consume foods that are low in sodium to reduce the development of edema and ascites. A nurse is caring for a client who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days ago. Which of the following actions should the nurse take? Perform pin site care daily. Remove the overbed trapeze. Remove the boot every 2 hr. Keep the weights on a stable, flat surface. - ✔✔Perform pin site care daily. RAT: The nurse should perform pin site care daily with chlorhexidine solution or use a solution according to facility protocol. The nurse should also monitor the pin sites for manifestations of infection. A nurse is caring for a client and administer penicillin IM. The client begins exhibiting hives and has severe difficulty breathing. After establishing a patent airway, which of the following actions should the nurse take next?term-17 Administer epinephrine. Monitor the client's vital signs. Monitor the client's oxygen saturation level. Administer an antihistamine. - ✔✔Administer epinephrine. RAT: The greatest risk to the client is death from anaphylaxis. Therefore, the nurse should administer epinephrine to reduce bronchospasms and laryngeal edema. A nurse is caring for a client who is 1 day postoperative following a hip arthroplasty. The client is exhibiting hypotension, tachycardia, and tachypnea. The nurse should recognize that these findings indicate which of the following complications? Wound infection Pulmonary embolism Thrombophlebitis Paralytic ileus - ✔✔Pulmonary embolism RAT: Manifestations of a pulmonary embolism include hypotension, tachycardia, and tachypnea. A nurse is examining a client's IV site and notes a red line up their arm. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client's manifestations indicate which of the following complications of IV therapy ? Thrombophlebitis Infiltration Hematoma Venous spasms - ✔✔Thrombophlebitis RAT: The nurse should identify pain, warmth, and a red streak up the arm as indications of thrombophlebitis. A nurse is preparing to auscultate the bowel sounds of a client who has a mechanical bowel obstruction in the descending colon. When listening in the left upper quadrant, the nurse should identify this sound as which of the following? Hyperactive bowel sounds Friction rub Normal bowel sounds Abdominal bruit - ✔✔Hyperactive bowel sounds RAT: A mechanical bowel obstruction prevents a portion or all of the bowel contents from moving forward through the bowel. The nurse should expect to auscultate high-pitched, hyperactive bowel sounds above the point of the intestinal obstruction as the intestines attempt to propel the blockage forward. A nurse is reinforcing teaching about glycosylated hemoglobin (HbA1c) testing with a client who has diabetes mellitus. Which of the following statements indicates that the client understands the teaching? "The HbA1c test should be performed 2 hr after I eat a meal that is high in carbohydrates." "The HbA1c test can help detect the presence of ketones in my body." "I will have my HbA1c checked twice per year." "I will plan to fast before I have my HbA1c tested." - ✔✔"I will have my HbA1c checked twice per year." RAT: An HbA1c test provides the client's average glucose level for the preceding 3 months. The nurse should instruct the client to have their HbA1c tested twice yearly to manage their glucose. A nurse is contributing to the plan of care for a client who was admitted to the neurological unit following a stroke 3 hr ago. Which of the following interventions should the nurse identify as the priority? Encourage the client to participate in self-care. Assist the client with active range-of-motion exercises. Keep the client in a side-lying position. Maintain the client's body alignment. - ✔✔Keep the client in a side-lying position. RAT: The greatest risk to the client following a stroke is aspiration. The nurse should position the client in a lateral, or side-lying, position to allow any secretions to drain out of the mouth, decreasing the risk for aspiration. Additionally, the nurse should have suction equipment available in the event that any secretions are present in the oral cavity. A nurse is reinforcing teaching with a client who is on a low-sodium diet and asks about how to improve the taste of bland food. Which of the following foods should the nurse recommend? Ketchup Mayonnaise Soy sauce Lemon juice - ✔✔Lemon juice RAT: The nurse should recommend that the client use lemon juice to flavor their food because it is low in sodium. A nurse is reviewing the laboratory results of a client who has type 2 diabetes mellitus. The nurse should identify that which of the following laboratory values indicates the client is at risk for delayed wound healing? HbA1c 6% Prealbumin 12 mg/dL WBC count 8,000/mm3 Creatinine 0.8 mg/dL - ✔✔Prealbumin 12 mg/dL RAT: This laboratory value is below the expected reference range, indicating that the client's protein status is inadequate and that they are at risk for delayed wound healing due to malnutrition. A nurse is preparing to perform intermittent urinary catheterization for a female client who has been unable to void following surgery 6 hr ago. Which following catheters should the nurse use to perform this procedure? - ✔✔(this was the last answer) RAT: This is an intermittent straight catheter and is the correct catheter for the nurse to use. A nurse is participating in a health fair for older adult clients. Which of the following vaccines should the nurse recommend for this age group? Meningococcal Herpes zoster Human papillomavirus (HPV) Measles, mumps, and rubella (MMR) - ✔✔Herpes zoster RAT: The nurse should recommend the herpes zoster vaccine for adults who are 60 years of age and older. A nurse is is reinforcing with a client who has multiple sclerosis and a new prescription for baclofen. Which of the following instructions should the nurse include in the teaching? Consume a low-purine diet. Avoid stopping this medication suddenly. Use chamomile tea to alleviate insomnia. 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