NURSING FUNDAMENTALS ATI Med-Surg Assessment A. 100 Questions and Answers with Rationale.

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ATI MEDICAL SURGICA-A 1. A nurse is caring for a client who is having a seizure. Which of the following interventions in the nurse’s priority? 2. A nurse is caring for a group of clients. The nu... rse should plan to make a referral to physical therapy for which of the following clients? 3. A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The nurse should postpone the testing and report to the provider which of the following findings? 4. 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 neurologic deficits should the nurse expect to find when assessing the client? (SATA) 5. A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take? 6. A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place which of the following items at the client’s bedside table? 7. A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish a ureterostomy. Which of the following statements should the nurse include in the teaching? 8. A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit? 9. A nurse is planning care for a client who is undergoing brachytherapy via a sealed vaginal implant to treat endometrial cancer. Which of the following actions should the nurse include in the client’s plan of care? 10. A nurse is planning to provide discharge teaching for the family of an older adult client who has hemianopsia and is at risk for falls. Which of the following instructions should the nurse include? 11. A nurse is planning care to decrease psychosocial health issues for a client who is starting dialysis treatments for chronic kidney disease. Which of the following interventions should the nurse include in the plan? 12. A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which of the following findings indicate that the client is experiencing increased intracranial pressure? (SATA) 13. An older adult client is brought to an emergency department by a family member. Which od the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration? 14. A nurse is caring for client who has a prescription for enalapril. The nurse should identify which of the following findings as an adverse effect of the medication? 15. A nurse in a provider’s office is caring for a client who requests sildenafil to treat erectile dysfunction. Which of the following statements should the nurse make? 16. 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? 17. A nurse is teaching a class about client rights. Which of the following instructions should the nurse include? 18. A nurse is caring for a client who is receiving morphine for daily dressing changes. The client tells the nurse, “I don’t want any more morphine because I don’t want to get addicted”. Which of the following actions should the nurse take? 19. A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. Which of the following prescribed medications should the nurse instruct the client to withhold for 48hr prior to cardioversion? 20. A nurse is caring for a client 1 hr following a cardiac cath. The nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions is the nurse’s priority? 21. A nurse is assessing a client who has Graves’ disease. Which of the following images should indicate to the nurse that the client has exophthalmos? 22. A nurse is caring for a client who has a stage III pressure injury. Which of the following findings contributes to delayed wound healing? 23. A nurse is providing teaching to a client who is receiving chemo and has a new prescription for epoetin alfa. Which of the following statements indicated an understanding of the teaching? 24. A nurse is providing discharge instructions to a client following an upper gastrointestinal series with barium contrast. Which of the following information should the nurse provide? 25. A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurse’s priority? 26. 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? 27. 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? 28. A nurse is providing preoperative teaching for a client who is scheduled for an open cholecystectomy. Which of the following actions should the nurse take? 29. Nurse and assistive personnel are caring for a client who has bacterial meningitis. The nurse should give the AP which of the following instructions? 30. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take? 31. A nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. Which of the following statements by the client indicates an understanding of the teaching? 32. A nurse is caring for a client who has hepatic encephalopathy that is being treating with lactulose. The client is experiencing excessive stools. Which of the following findings is an adverse effect of this medication? 33. A nurse is providing teaching to an older adult female client who has stress incontinence and a BMI of 32. Which of the following statements by the client indicates an understanding of the teaching? 34. A nurse is caring for a client who has type 1 diabetes mellitus and has acute bronchitis for the past 3 days. Which of the following statements should the nurse include when instructing the client? 35. A nurse is caring for a client who is on bed rest and has a new prescription for enoxaparin subQ. Which of the following action should the nurse take? 36. A nurse is caring for a client who is undergoing hemodialysis to treat end-stage kidney disease. The client reports muscle cramps and a tingling sensation in their hands. Which of the following medications should the nurse plan to administer? 38. A nurse is assessing a client following the administration of magnesium sulfate 1g IV bolus. For which of the following adverse effects should the nurse monitor? 39. A nurse is caring for a client who has diabetic ketoacidosis. Which of the following lab findings should the nurse expect? 40. A nurse is providing teaching to a client who has irritable bowel syndrome. Which of the following instructions should the nurse include in the teaching? 41. A nurse is caring for a client who has pancreatitis. The nurse should expect which of the following laboratory results to be below the expected reference range? 42. A client who has pancreatitis is expected to have decreased calcium and magnesium levels due to fat necrosis. 43. A nurse is assessing a client who had extracorporeal shock wave lithotripsy 6 hr ago. Which of the following findings should the nurse expect? 44. A nurse is creating a plan of care for a client who has neutropenia as a result of chemotherapy. Which of the following interventions should the nurse include in the plan? 45. A nurse is assessing a group of clients for indications of role changes. The nurse should identify that which of the following clients is at risk for experiencing a role change? 46. A nurse in a provider’s office is assessing a client who has migraine headaches and is taking feverfew to prevent headaches. The nurse should identify that which of the following client medications interacts with feverfew? 47. A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV contrast agent. The nurse should identify that which of the following findings requires further assessment? 48. A nurse has received change-of-shift report for a group of clients. Which of the following clients should the nurse assess first? 49. A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a productive cough. Which of the following actions should the nurse take first? 50. A nurse is caring for a client who has a new prescription for total parental nutrition. The client is to receive 2,000 kcal per day. The TPN solution has 500 kcal/L. The IV pump should be set at how many mL/hr? 51. A nurse is an emergency department is caring for a client who has full thickness burns over 20% of their total body surface area. After ensuring a patent airway and administering oxygen, which of the following items should the nurse prepare to administer first? 52. A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure injury. Which of the following actions should the nurse take? 53. A nurse is providing teaching for a female client who has recurrent UTI. Which of the following info should the nurse include in the teaching? 54. A nurse is caring for a client who is experiencing supraventricular tachycardia. Upon assessing the client, the nurse observes the following findings: HR 200 B/P 78.40 RR 30. Which of the following actions should the nurse take? 55. A nurse is providing teaching to an older adult client who has cancer and a new prescription for an opioid analgesic for pain management. Which of the following information should the nurse include in the teaching? 56. A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of the following precautions should the nurse implement? 57. A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for omeprazole. The nurse should instruct the client that the medication provides relief by which of the following actions? 58. A nurse is caring for 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? 60. A nurse is assessing a male client for an inguinal hernia. Which of the following areas should the nurse palpate to verify that the client has an inguinal hernia? 61. A nurse in an emergency department is caring for a client who is experiencing a thyroid storm. Which of the following manifestations should the nurse expect? 62. A nurse is performing a dressing change for a client who is recovering from a hemicolectomy. When removing the dressing, the nurse notes that a large part of the bowel is protruding through the abdomen. Which of the following actions should the nurse take first? 64. A nurse is providing discharge instructions to a client who has a partial thickness burn on the hand. Which of the following instructions should the nurse include? 65. A nurse is caring for a client who has HIV. Which of the following findings indicates a positive response to the prescribed HIV treatment? 66. A nurse is caring for a client who is receiving TPN. A new bag is not available when the current infusion is nearly completed. Which of the following actions should the nurse take? 67. A nurse is assessing a client who has had a suspected stroke. The nurse should place priority on which of the following findings? 68. A nurse in a provider’s office is assessing a client who has hypertension and takes propranolol. Which of the following findings should indicate to the nurse that the client is experiencing an adverse reaction to this medication? 69. A nurse in an emergency department is assessing a client who has a detached retina. Which of the following should the nurse expect the client to report? 70. A nurse is providing teaching to a female client who has a history of UTI. Which of the following information should the nurse include in the teaching? 71. A nurse in an emergency department is reviewing the provider’s prescriptions for a client who sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the nurse suspect? 72. A nurse is caring for a client who has chronic glomerulonephritis with oliguria. Which of the following findings should the nurse identify as a manifestation of chronic glomerulonephritis? 73. A nurse in a community clinic is caring for a client who reports an increase in the frequency of migraine headaches. To help reduce the risk for migraine headaches, which of the following foods should the nurse recommend the client avoid? 74. A nurse is assessing a client who has had a plaster cast applied to their left leg 2 hr ago. Which of the following actions should the nurse take? 75. A nurse is caring for a client who has viral pneumonia. The client’s pulse ox readings have fluctuated between 79% and 88% for the last 3o min. Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen? 76. A nurse is caring for a client who has a new diagnosis of hyperthyroidism. Which of the following is the priority assessment finding that the nurse should report to the provider? 77. A nurse is teaching a young adult client how to perform testicular self-exams. Which of the following instructions should the nurse include? 78. A nurse is caring for a client who has a potassium level 3. Which of the following assessment findings should the nurse expect? 79. A nurse is reviewing the lab results of a client who has cirrhosis. Which of the following lab values should the nurse expect? 80. A nurse is providing discharge teaching to a client who has heart failure and a new prescription for a potassium-sparing diuretic. Which of the following information should the nurse include in the teaching? 81. A nurse is evaluating a client who has a new diagnosis of type 1 diabetes mellitius. Which of the following client statements indicates the client is successfully coping with the change? 82. A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of the medication? 83. A nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. Which of the following statements should the nurse identify as an indication that the client understands the teaching? 84. A nurse is performing a cardiac assessment for a client who had a MI 2 days ago. Which of the following actions should the nurse take first after hearing the following sound? 85. A nurse is teaching a client who has venous insufficiency about self-care. Which of the following statements should the nurse identify as an indication that the client understands the teaching? 86. A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? 87. A nurse is caring for a client who presents to a clinic for a 1 week follow up visit after hospitalization for a heart failure. Based on the information in the client’s chart, which of the following findings should the nurse report to the provider? 88. A nurse is providing instructions to a client who has type 2 DM and a new prescription for metformin. Which of the following statements by the client indicates an understanding of the teaching? 89. A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing’s triad? 90. A nurse is providing dietary teaching to a client who is postoperative following a thyroidectomy with removal of the parathyroid glands. The nurse should instruct the client to include which of the following foods that has the greatest amount of calcium in her diet? 91. A nurse is caring for a client who has portal hypertension. The client is vomiting blood missed with food after a meal. Which of the following actions should the nurse take first? 92. A nurse is caring for a client who is postoperative following a total hip arthoplasty. Which of the following lab values should the nurse report to the provider? 93. A nurse is caring for a client who has amyotrophic lateral sclerosis and is being admitted to the hospital with pneumonia. Which of the following assessment findings is the nurse’s priority? 94. A nurse is caring for a client who has a leg cast and is returning demonstration on the proper use of crutches while climbing stairs. Identify the sequence the client should follow when demonstrating crutch use. [Show More]

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