RN VATI Adult Medical Surgical (answered) Summer 2021: all questions answered correctly.

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RN VATI Adult Medical Surgical (answered) Summer 2021: all questions answered correctly. A nurse is caring for a client who has atopic dermatitis and a prescription for triamcinolone ointment. The ... nurse should assess the client to monitor for which of the following adverse effects? Correct Answer: Thinning of the skin. Only apply the ointment to dry patches of the skin to avoid atrophy. Topical Glucocorticoids Side effects Correct Answer: Tiamcinolone - Hypopigmentation - Excessive hair growth (hypertrichosis) - Thinning of the skin A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse identify as a manifestation of left-sided heart failure? Correct Answer: Frothy sputum Pink-tinged frothy sputum can be an early indication of pulmonary edema and can be life-threatening. Therefore, the nurse should notify the provider immediately. Left Sided Heart Failure Correct Answer: - Frothy sputum - Dyspnea - Wheezing Treatment: Fluid restriction & diuretics to decrease preload & pulmonary congestion Right heart sided failure Correct Answer: - Dependent edma - Jugular distention - Weight gain A nurse is caring for a client who is experiencing anxiety as well as numbness and tingling of the lips and fingers. The client's ABGs are: pH 7.48, PCO2 30 mm Hg, HCO3- 24 mEq/L, PaO2 85 mm Hg. Which of the following acid-base imbalances should the nurse identify that the client is experiencing? Correct Answer: Respiratory alkalosis - The pH is alkaline - PCO2 is low representing alveolar hyperventilation & respiratory alkalosis A nurse is assessing a client who has Cushing's syndrome. Which of the following findings should the nurse expect? Correct Answer: Osteoporosis Bone become thinner as a result of mineral loss & nitrogen depletion. A nurse is inspecting the skin of a client who has basal cell carcinoma. The nurse should identify which of the following lesion characteristics on the client's skin? Correct Answer: A pearly, waxy nodule. - Basal cell carcinoma has a nodular lesion with well defined borders & pearly or waxy apperance from ocerexposure to the sun. Melanoma Correct Answer: Irregular border and varigated colored lesions of red, white, blue. - Most often on the upper back or lower legs Squamous cell carcinoma Correct Answer: Firm, nodular, and crusty lesion with an ulcerated center from sun exposure, chronic irritation, burns, or irradiation to the skin. weeping vescile Correct Answer: Herpes Zoster - Weeping, blister type lesions. A nurse in an emergency department is assessing a client who is overusing prescribed diuretics and has a sodium level of 127 mEq/L. Which of the following laboratory findings should the nurse expect? Correct Answer: LOW URINE SPECFIC GRAVITY. Hyponatremia Correct Answer: - Low specific gravity - Elevated hemoglobin A home health nurse is assisting a client with planning care for a family member who has Alzheimer's disease. Which of the following instructions should the nurse include? Correct Answer: Remove clutter from rooms and hallways - This allows the client is able to walk without the risk of falling or tripping over objects. Later in the disease, the client can experience seizures, so cluttered areas could be a risk to the client Alzheimer's interventions Correct Answer: - Single date calender - Redirect the client by starting another activity - Use short, simple senteces when explaining an activity - Explanation should be done immediately before an activity A nurse is caring for a client who has developed acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse identify as a manifestation of this syndrome? Correct Answer: REFRACTORY HYPOXEMIA - A client who has ARDS has refractory hypoxemia, which is hypoxemia that does not improve with oxygen therapy. Extensive pulmonary edema evident on a chest x-ray is a manifestation of ARDS. Pulmonary embolism Correct Answer: - Pleural friction rub - Tachypnea - Tachycardia - Dyspnea - Sudden, sharp chest pain Tension pneumothorax Correct Answer: - Trachial deviation - Dyspnea - Tachycardia - Tachypnea - Decreased or absent breath sounds over area Lung cancer Correct Answer: Hemoptysis Bloody expectorant when coughing An emergency room nurse is assessing a client who has asthma and difficulty breathing. Which of the following findings should indicate to the nurse that the client is experiencing status asthmaticus? Correct Answer: USE OF ASSCESSORY MUSCLES. - A client who has status asthmaticus uses accessory muscles to help facilitate breathing, which is a manifestation of a severe airflow obstruction. The situation is life-threatening and the nurse should intervene immediately with strong systemic bronchodilators, epinephrine, corticosteroids, and oxygen. status asthmaticus Correct Answer: - Labored breathing & wheezing - Distended neck veins - Use of accessory muscle - Bronchodilators - Epinephrine - Corticosteroids - Oxygen A nurse is teaching a client who has a new prescription for PHENYTOIN to treat a seizure disorder. Which of the following adverse effects should the nurse instruct the client to report IMMEDIATELY to the provider? Correct Answer: SKIN RASH. - the nurse should determine that the priority finding is a rash, which can have a measles-like appearance and progress to exfoliative dermatitis or Stevens-Johnson syndrome. The client should report this finding to the provider immediately. Phenytoin side effects Correct Answer: - Skin Rash - Bleeding gums - Increased facial hair - Constipation A nurse is monitoring a client following a LUMBAR LAMINECTOMY. The client has a drain and indwelling urinary catheter. The nurse should identify which of the following findings as an indication of a COMPLICATION of the surgery? Correct Answer: CLEAR DRAINAGE OF DRESSINGS - This is an indication of a cerebral spinal leak lumbar laminectomy postoperative Correct Answer: - Slight elevation in temperature - No more than 125 mL of drainage in 4 hours - Decreased bowel sounds due to anesthesia - Monitor for paralytic ileus A nurse is assessing a client who has RIGHT-SIDED HEART FAILURE. Which of the following findings should the nurse identify as a manifestation of RIGHT- SIDED HEART FAILURE? Correct Answer: INCREASED ABDOMINAL GIRTH A nurse is caring for a client who recently assumed the role of caregiver for their aging parents who have chronic illnesses. The nurse should identify that which of the following statements by the client indicates ACCEPTANCE of the role change? Correct Answer: " I changed the floor plan of our homes to accommodate my father's wheelchair. " A nurse is caring for a client who is receiving VANCOMYCIN intermittent IV bolus therapy for METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS. Which of the following findings is an indication to the nurse that the client is experiencing an ADVERSE EFFECT of the medication? Correct Answer: THE CLIENT IS BECOMING FLUSHED. - Flushing is a manifestation of an infusion reaction to vancomycin that also causes a rash on the face and upper body, called red man syndrome. Red man sydrome Correct Answer: Results from infusing vancomycin too rapidly. The nurse should infuse the medication over at least 60 min. - Hypotension - Tachycardia - Ototoxcity - Renal failure - Flushing A nurse is caring for a male client who has a new prescription for CYCLOSPORINE following a kidney transplant. Which of the following findings should the nurse identify as an adverse effect of this therapy? Correct Answer: BUN 24 mg/dL. - A BUN of 24 mg/dL is above the expected reference range of 10 to 20 mg/dL, indicating renal impairment. An adverse effect of cyclosporine is nephrotoxicity WBC normal range Correct Answer: 5,000-10,000 RBC count normal range Correct Answer: 4.7-6.1 million Potassium normal range Correct Answer: 3.5-5.0 A nurse is caring for a client who has DUMPING SYNDROME following a gastric resection. The nurse should monitor the client for which of the following complications of DUMPING SYNDROME? Correct Answer: IRON DEFICIENCY ANEMIA. - The nurse should monitor the client for manifestations of anemia, such as pallor, tachycardia, and fatigue. Rapid emptying of the stomach contents into the intestine can lead to reduced absorption of iron in the duodenum, causing iron-deficiency anemia. A nurse is assessing a client who takes SALMETEROL to treat moderate asthma. Which of the following findings should indicate to the nurse that the medication has been effective? Correct Answer: THE CLIENT'S FORCED EXPIRATORY VOLUME IS DECRESED AFTER TREATMENT WITH MEDICATION. - Forced expiratory volume measures the amount of air the client exhales during 1 second and is part of pulmonary function testing. Effective use of a bronchodilator should increase the client's forced expiratory volume Dumping syndrome Correct Answer: - Anorexia - Iron deficiency anemia - Hypocalcemia - Tachycardia - Rapid gastric emptying - Nausea & abdomnial cramping A nurse is providing teaching about health promotion activities for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? Correct Answer: " I WILL CHECK MY BLOOD SUGAR LEVEL BEFORE EXCERCISING. " - Clients who have diabetes mellitus should not exercise if their blood glucose level is less than 80 mg/dL or greater than 250 mg/dL. A client who has type 1 diabetes mellitus and is hyperglycemic can experience even higher blood glucose levels. Hypoglycemia can also occur during exercise and up to 24 hr following exercise A nurse is providing teaching to a client who has a new prescription for WARFARIN. Which of the following medications should the nurse instruct the client to avoid? Correct Answer: ASPIRIN & NAPROXEN. - Aspirin is an antiplatelet medication. It can increase the risk of bleeding when taken with warfarin. - . Naproxen is an NSAID that relieves mild to moderate pain. It can increase the risk of bleeding if taken with warfarin. A nurse is assisting with the care of a client who is scheduled for a THORACENTESIS. Which of the following interventions should the nurse plan to take? Correct Answer: PLACE THE CLIENT LEANING FORWARD OVER THE BEDSIDE TABLE FOR THE PROCEDURE. - This allows the provider complete access to the client's chest and back. This position also expands the spaces between the ribs where the pleural fluid accumulates. paracentesis Correct Answer: - Empty the bladder before the procedure - Weigh the client before and after procedure - Keep the client on bedrest after the procedure A nurse is providing discharge teaching about infection control at home for a client who has TUBERCULOSIS. Which of the following statements by the client indicates an understanding of the teaching? Correct Answer: " I will place my used tissues in a plastic bag. " - The sputum of a client who has tuberculosis is considered infectious until there are three consecutive sputum samples that test negative for Mycobacterium tuberculosis. Tissues that are soiled with the client's sputum should be placed in a plastic bag and sealed to avoid spreading the infection A nurse is teaching a client who is scheduled to receive RADIOACTIVE IODINE THERAPHY for treatment of hyperthyroidism. Which of the following instructions should the nurse include in the teaching? Correct Answer: USE DISPOSABLE UTENSILS FOR MEALS. - The client who receives radioactive iodine has radioactivity in the body fluids, including saliva, for several weeks following treatment. The nurse should instruct the client to use disposable utensils, plates, and cups during this time period to decrease the risk for radiation exposure to other members of the household Radiation therapy interventions Correct Answer: - Remain 1m (3ft) away from infants, children, and pregnant women. - 1-hour of limited exposure to pregnant women - Use disposable utensils - Condom catheter & drainage bag - Facial tissues in underwear A nurse is providing preoperative teaching to a client who is scheduled for a RADICAL PROSTATECTOMY. Which of the following information should the nurse include in the teaching? Correct Answer: A PCA PUMP WILL BE USED FOR POSTOPERATIVE PAIN CONTROL. - A PCA pump is a common method of pain management in the first 24 hr following an open radical prostatectomy. The nurse should teach the client how to manage pain during the preoperative period rather than waiting until after surgery when the client is feeling the sedative effects of the anesthesia and pain medication. A nurse is assessing a client's ECG strip and notes an irregular heart rate of 98/min with NO CLEAR P WAVES. Which of the following cardiac dysrhythmias should the nurse document? Correct Answer: ATRIAL FIBRILLATION. - With atrial fibrillation, multiple rapid impulses from many different foci cause depolarization of the atria in a rapid, disorganized manner. This causes a chaotic rhythm on the ECG strip that has no clear P waves, no atrial contractions, and an irregular rhythm. First-degree heart block Correct Answer: - Atrial impulses reach the ventricles through the AV node at a slower-than-normal rate. - P waves have a regular shape and appear consistently in front of the QRS complex. Complete heart block Correct Answer: - Regular rhythm - Low HR - Clear P waves that outnumber QRS complexes - Ventricular tachycardia Correct Answer: - Rapid, regular rhythm - HR: 140 + - P waves not visible A nurse is caring for a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take? Correct Answer: REPORT CLOUDY DIALYSATE DRAINAGE TO THE PROVIDER. - The most serious complication of peritoneal dialysis is peritonitis, an inflammation of the peritoneum. Assessment findings include cloudy dialysate drainage, rebound abdominal tenderness, and diffuse abdominal pain. The nurse should report these findings immediately to the provider, who can then prescribe a fluid culture, quick exchanges to wash out mediators of infection, and antibiotics. Dialysate interventions Correct Answer: - Do NOT use infusion pump - Report cloudy dialysate drainage - Warm solution using a heating pad or place in the warming section of cycling machine - Dwell time: 4-8 hours - Drainage: 10-20 minutes A nurse is assessing a client who has suspected APPENDICITIS. Which of the following manifestations should the nurse expect? Correct Answer: - Elevated WBC count (20,000+) - Rebound tenderness (RLQ) - Anorexia A nurse is planning preventative strategies for a client who is at risk for PRESSURE INJURIES. Which of the following actions should the nurse include in the plan? Correct Answer: APPLY MOISTURIZER TO DAMP SKIN AFTER BATHING. - Applying a moisturizer to damp skin after bathing helps prevent dry skin. The drier the skin is, the greater the risk is for skin breakdown. A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following findings should the nurse identify as a manifestation of TYPE 1 DIABETES? Correct Answer: KETONES IN THE URINE - Clients who have type 1 diabetes mellitus can have ketones in the urine, which are a byproduct of the breakdown of fats for energy. Ketones in the urine are an indicator of inadequate amounts of insulin and high blood glucose levels Type 1 diabetes S/S Correct Answer: - Hyponatremia - Increased serum osmolality - Ketone in the urine - Hyperglycemia A nurse is caring for a client who had a surgical repair of an ABDOMINAL AORTIC ANEURYSM 3 days ago. The client's vital signs are: temperature 38.3° C (100.9° F), heart rate 80/min, respirations 16/min, and blood pressure 128/76 mm Hg. Which of the following actions is the nurse's priority? Correct Answer: ASSESS THE SURGICAL INCISION FOR SIGNS OF INFECTION. - A surgical wound infection typically appears 3 to 6 days following the surgery. Fever from the third postoperative day onward indicates that this client's greatest risk is either a wound infection or a pulmonary infection; therefore, this is the priority action the nurse should take. A nurse is providing discharge teaching to a client following a loop electrosurgical ex [Show More]

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