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Exam (elaborations)

ATI RN Medsurg 2023

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ATI RN Medsurg 2023 A nurse is teaching a client who has heart failure about self-management techniques. Which of the following statements by the client indicates an understanding of the teaching? A. I will keep an exercise diary B. I will take ibuprofen for mild pain C. I will expect swel...

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  • May 26, 2024
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  • 2023/2024
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  • ATI RN Medsurg 2023
  • ATI RN Medsurg 2023
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ATI RN Medsurg 2023
A nurse is teaching a client who has heart failure about self-management techniques. Which of the following statements by the client indicates an understanding of the teaching? A. I will keep an exercise diary B. I will take ibuprofen for mild pain C. I will expect swelling in my feet and ankle D. I will weight myself every other day - ANSWER C. I will expect swelling in my feet and ankle
A nurse is providing discharge teaching for a client who has new tracheostomy. Which of the following statements by the client indicates an understanding of the teaching? A. I'll insert the obturator after cleaning my stoma B. I'll cut a slit in a clean gauze pad to use as a stoma dressing C. I'll cleanse the cannula with half strength hydrogen peroxide D. I'll remove the soiled tracheostomy ties prior to cleaning my stoma - ANSWER C. I'll cleans the cannula with half strength hydrogen peroxide
A nurse is caring for a client who has a sealed radiation implant which of the following actions should the nurse take? A. Limit family member visits to 30 min per day B. Give the dosimeter badge to the oncoming nurse at the end of the shift C. Apply second pair of gloves before touching the clients implant if it dislodges D. Remove soiled lines from the room after each change - ANSWER A. Limit family member visits to 30 min per day A nurse is reviewing the medical record of a client who has pneumonia. Which of the following serum laboratory values should the nurse expect? A. WBC count 15,000/mm B. Hematocrit 35% C. Sodium 130 mg/dL
D. BUN 8 mg/dL - ANSWER A. WBC count
15,000/mm
A nurse is planning care for a client who has a newly implanted arteriovenous graft
in the right arm. Which of the following actions should the nurse include in the plan of care? A. Instruct the client to avoid lifting the right arm for 72 hr
B. Check blood pressure in the right arm C. Palpate the site for thrill D. Insert a saline lock into a site 10 cm (4 in) distal to the graft - ANSWER C. Palpate the site for thrill
A nurse is performing a venipuncture on an older adult client whose veins are difficult. Which of the following actions should the nurse take? A. Apply cool compresses B. Elevate the client's extremity using a pillow C. Tap the skin around the insertion site D. Raise the angle of the catheter to 30 degrees above the insertion site - ANSWER C. Tap the skin around the insertion site
A nurse is caring for a client in the ER following a myocardial infarction. Which of
the following actions should the nurse anticipate if the client develops asystole?
A. Administer atropine B. Defibrillate with 200 joules C. Start a continuous lidocaine infusion D. Begin CPR - ANSWER D. Begin CPR A nurse is caring for a client with severe burn injury. The nurse should recognize which of the following client findings as an indication of hypovolemic shock?
A. Potassium 5.2 mEq/L B. Capillary refill 1.5 seconds C. Urine output 45 mL/hr D. PaCO3 37 mmHg - ANSWER A. Potassium 5.2 mEq/L
A critical care nurse is assessing a client who has a severe head injury. In response to painful stimuli the client does not open her eyes, displays decerebrate posturing, and makes incompressible sounds. Which of the following Glasgow coma scale scores should the nurse assign the client? A. 2 B. 5 C. 10 D. 13 - ANSWER B. 5
A nurse in the emergency department is caring for a client who has a gunshot wound to the abdomen. Which of the following should the nurse take first? A. Check the color of the client's skin B. Prepare the client's clothing C. Remove all the clients clothing D. Administer an opioid analgesic - ANSWER A. Check the color of the client's skin
A nurse is assessing a client who has an arteriovenous (AV) fistula in the left forearm. Which of the following findings should the nurse identify as an indication
of a complication at the vascular access site? A. Presence of palpable thrill B. 2+ left radial pulse C. Absence of bruit

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