ATI Med Surg Proctored 2023
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Ensure the client has a patient IV
A nurse in an acute care facility is
caring for a client who is at risk for The nurse should ensure the client has
seizures. Which of the following precau- IV access in the event
tions should the nurse implement? that the client requires medication to stop
seizure activity
Hgb 8 g/dL
A nurse is caring for a client who is post-
operative following a total hip arthroplas- The nurse should report an Hgb level of
ty. Which of the following laboratory val- 8 g/dL, which is below
ues should the nurse report to the expected reference range and is an
the provider? indicator of postoperative hemorrhage or
anemia
Stone fragments in the urine
A nurse is assessing a client who had ESWL is an effort to break the calculi so
extracorporeal shock wave lithotripsy that the fragments pass down the ureter,
(ESWL) 6 hr ago. Which of the following into the bladder, and through the urethra
findings should the nurse expect? during voiding. Following the procedure,
the nurse should strain the client's urine
to confirm the passage of stones
Initiate airborne precautions
A nurse is caring for a client who has This client is exhibiting manifestations
anorexia, low-grade fever, night sweats, of tuberculosis. The greatest risk in this
and a productive cough. Which of the client situation is for other people in the
following actions should the nurse take facility to acquire an airborne disease
first? from this client. Therefore, the first action
the nurse should take is to initiate air-
borne precautions
Administer dextrose 10% in water until
A nurse is caring for a client who is re-
the new bag arrives
ceiving total parenteral nutrition (TPN). A
new bag is not available when the current
TPN solutions have a high concentra-
infusion is nearly completed. Which of
tion of dextrose. Therefore, if a TPN solu-
the following actions should the nurse
tion is temporarily unavailable, the nurse
take?
should administer dextrose 10% or 20%
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in water to avoid a precipitous drop in the
client's blood glucose level.
Calcium
Calcium limits the development of os-
A nurse is providing teaching to a client
teoporosis in clients who are post-
who has hypothyroidism and is receiving
menopausal and works as an antacid.
levothyroxine. The nurse should instruct
Calcium supplements can interfere with
the client that which of the following sup-
the metabolism of a number of medica-
plements can interfere with the effective-
tions, including levothyroxine. The nurse
ness of the medication?
should instruct the client to avoid taking
calcium within 4 hr of levothyroxine ad-
ministration.
Instruct the client to allow the machine to
breathe for them.
When providing client care, the nurse
A nurse is caring for a client who has
should first use the least
emphysema and is receiving mechani-
restrictive intervention. Therefore, the
cal ventilation. The client appears anx-
first action the nurse should take is to
ious and restless, and the high-pressure
provide verbal instructions and emotion-
alarm is sounding. Which of the following
al support to help the client relax and
actions should the nurse take first?
allow
the ventilator to work. Clients can exhibit
anxiety and restlessness when trying to
"fight the ventilator."
Orthostatic hypotension
A nurse is caring for a client who has
a prescription for enalapril. The nurse
The nurse should identify that dilation
should identify which of the following
of arteries and veins causes orthostatic
findings as an adverse effect of the med-
hypotension, which is an adverse effect
ication?
of enalapril.
Urine output 25 mL/hr
A nurse is caring for a client who has a
stage III pressure injury. Which of Urinary output reflects fluid status. Inad-
the following findings contributes to de- equate urine output can
layed wound healing? indicate dehydration, which can delay
wound healing.
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"You should void every 4 hours to de-
A nurse is providing teaching to an older
crease the risk of urinary retention."
adult client who has cancer and a new
prescription for an opioid analgesic for
The nurse should instruct the client to
pain management. Which of the follow-
void at least every 4 hr to decrease the
ing information should the nurse include
risk of urinary retention, which is an ad-
in the teaching?
verse effect of opioid analgesics
Obtain vital signs.
The first action the nurse should take us-
ing the nursing process is to assess the
A nurse is caring for a client who has
client's vital signs. A client who has portal
portal hypertension. The client is vomit-
hypertension can develop esophageal
ing blood mixed with food after a meal.
varices, which are fragile and can rup-
Which of the following actions should the
ture, resulting in large amounts of blood
nurse take first?
loss and shock. Obtaining vital signs
provides information about the client's
condition that can contribute to decision
making.
- Avoid drinking fluids with meals
- Eat several small meals per day
- Consume high-protein snacks
- Avoid highly seasoned foods
:Maintain a high carbohydrate intake is
incorrect. Dumping syndrome requires a
A nurse at a provider's office is caring
low carbohydrate diet because of reac-
for a client who is 2 weeks postoperative
tive hypoglycemia. Eat five servings of
following a gastrectomyA nurse is provid-
fresh fruit per day is incorrect. The client
ing teaching for the client. Which of the
should limit intake to three servings of
following instructions should the nurse
unsweetened cooked or canned fruit per
include?
day. Avoid drinking fluids with meals is
correct. The nurse should instruct the
client to drink fluids 30 min before or after
meals
Eat several small meals per day is cor-
rect. The nurse should instruct the client
to eat several small, frequent meals in-
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stead of three large meals per day. Con-
sume high-protein snacks is correct. The
client should eat snacks that are high in
protein and low in carbohydrates to pre-
vent the gastric food boluses and reac-
tive hypoglycemia in dumping syndrome.
Avoid highly seasoned foods is correct.
The nurse should instruct the client to
avoid excessive amounts of spices and
salt.
Bradycardia
A nurse in an ICU is assessing a client A client who has increased intracranial
who has a traumatic brain injury. Which pressure from a traumatic brain injury
of the following findings should the nurse can develop bradycardia, which is one
identify as a component of Cushing's tri- component of Cushing's triad. The other
ad? components of Cushing's triad are se-
vere hypertension and a widened pulse
pressure
"I used to never worry about my feet.
Now, I inspect my feet every day with a
A nurse is evaluating a client who has a mirror."
new diagnosis of type 1 diabetes melli-
tus. Which of the following client state- This statement indicates that the client is
ments indicates the client is successfully successfully coping with the change be-
coping with the change? cause the client is performing preventive
foot care to reduce the risk for complica-
tions
Administer an opioid analgesic to the
A nurse in an emergency department is
client.
reviewing the provider's prescriptions for
a client who sustained a rattlesnake bite
The nurse should expect a prescription
to the lower leg. Which of the following
for an opioid analgesic to promote com-
prescriptions should the nurse expect? -
fort following a rattlesnake bite
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