ATI RN MED SURGE PROCTORED EXAM QUESTIONS AND ANSWERS 100 COMPLETE AND GRADED A+

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A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.) 1) Dyspnea 2) Barrel chest 3) Clubbing of the fingers ... 4) Shallow respirations INCORRECT 5) Bradycardia Answer Rationale: Dyspnea is correct. Dyspnea is experienced by clients who have emphysema due to inadequate oxygen exchange in the lungs. Barrel chest is correct. The lungs of clients who have emphysema lose their elasticity, and the diaphragm becomes permanently flattened by overdistention of the lungs. The muscles of the rib cage also become rigid, and the ribs flare outward. This produces the barrel chest typical of emphysema clients. Clubbing of the fingers is correct. Air is trapped in the lungs due to their lack of elasticity, which decreases oxygenation. Clubbing results from these chronic low blood-oxygen levels. Shallow respirations is correct. Clients who have emphysema lose lung elasticity; consequently, respirations become increasingly shallow and more rapid. Bradycardia is incorrect. The heart rate will increase as the heart tries to compensate for less oxygen being delivered to the tissues. 2. A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical manifestations should the nurse expect to observe? (Select all that apply.) 1) Buffalo hump 2) Purple striations 3) Moon face INCORRECT 4) Tremors INCORRECT 5) Obese extremities Answer Rationale: Buffalo hump is correct. Cushing's syndrome is a disease caused by an increased production of cortisol or by excessive use of corticosteroids. Buffalo hump, a collection of fat between the shoulders, is a common manifestation of Cushing's syndrome.Purple striations is correct. Purple striations on the skin of the abdomen, thighs, and breasts are a common manifestation of Cushing's syndrome. This is due to the collection of body fat in these areas.Moon face is correct. Moon face is a common manifestation of Cushing's syndrome. Clients who have this manifestation present with a round, red, full face.Tremors is incorrect. Tremors are not a common finding of Cushing's syndrome.Obese extremities is incorrect. Clients who have Cushing's syndrome have truncal obesity, a protuberant abdomen, with thin extremities, which is due to an alteration in protein metabolism. 3. A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.) 1) Encourage fluid intake. 2) Monitor the puncture site for hematoma. INCORRECT 3) Insert a urinary catheter. INCORRECT 4) Elevate the client’s head of bed. INCORRECT 5) Apply a cervical collar to the client. Answer Rationale: Encourage fluid intake is correct. The nurse should encourage fluids, unless contraindicated, to replace the cerebrospinal fluid that was removed during the procedure and reduce the risk for a headache. A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following actions should the nurse take? 1) Provide a diet high in protein. 2) Provide ibuprofen for retroperitoneal discomfort. 3) Monitor intake and output hourly 4) Encourage the client to consume at least 2 L of fluid daily. A nurse is reinforcing teaching about an esophagogastroduodenoscopy with a client who has upper gastric pain. Which of the following statements should the nurse include in the teaching? 1) "A flexible tube is introduced through the nose during the procedure." 2) "During the procedure you are in a sitting position." 3) "You will remain NPO for 8 hours before the procedure." 4) "You will be awake while the procedure is performed." A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record? 1) Aura phase 2) Presence of automatisms 3) Postictal phase 4) Presence of absence seizures A nurse is reinforcing teaching with a client who reports right shoulder pain following a laparoscopic cholecystectomy. Which of the following statements should the nurse make? 1) "The pain results from lying in one position too long during surgery." 2) "The pain occurs as a residual pain from cholecystitis." 3) "The pain will dissipate if you ambulate frequently." 4) "The pain is caused from the nitrous dioxide injected into the abdomen." A nurse is checking the suction control chamber of a client's chest tube and notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? 1) Notify the provider. Answer Rationale: The nurse should check for kinks and take other measures before notifying the provider. 2) Verify that the suction regulator is on. 3) Continue to monitor the client because this is an expected finding. 4) Milk the chest tube to dislodge any clots in the tubing that may be occluding it. A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.) 1) Encourage fluid intake. 2) Monitor the puncture site for hematoma. 3) Insert a urinary catheter. 4) Elevate the client’s head of bed. 5) Apply a cervical collar to the client. A nurse is assisting with the care of a client who is postoperative following surgical repair of a fractured mandible. The client’s jaw is wired shut to repair and stabilize the fracture. The nurse should recognize which of the following is the priority action? 1) Relieve the client's pain. 2) Check the client’s pressure points for redness. A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching? 1) Take temperature once a day. 2) Wash the armpits and genitals with a gentle cleanser daily. 3) Change the litter boxes while wearing gloves. 4) Wash dishes in warm water. 1. A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions? 1) Provide humidified oxygen. 2) Perform chest physiotherapy prior to suctioning. 3) Prelubricate the suction catheter tip with sterile saline when suctioning the airway. 4) Hyperventilate the client with 100% oxygen before suctioning the airway.. 2. Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort? 1) Rub the client's feet briskly for several minutes. 2) Obtain a pair of slipper socks for the client. 3) Increase the client's oral fluid intake. 4) Place a moist heating pad under the client's feet. 3. A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for the nurse report to the provider? 1) Emesis of 100 mL 2) Oral temperature of 37.5° C (99.5° F) 3) Thick, red-colored urine 4) Pain level of 4 on a 0 to 10 rating scale 4. A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of the hypothermia blanket? [Show More]

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