ATI RN Adult Medical Surgical Practice H 2024
A nurse is caring for a client who has a leg cast and is returning to demonstrate on the proper use of crutches while climbing stairs. Identify the sequence the client should follow when demonstrating crutch use.
• Brings the crutches and the affe...
A nurse is caring for a client who has a leg cast and is returning to demonstrate on
the proper use of crutches while climbing stairs. Identify the sequence the client
should follow when demonstrating crutch use.
• Brings the crutches and the affected leg up to the stair
• Places body weight on the crutches
• Shifts weight from the crutches to the unaffected leg
• Advances the unaffected leg onto the stair
A nurse is caring for a client who has hypothyroidism. Which of the following
manifestations should the nurse expect?
Rationale: a client who has hypothyroidism can experience constipation due to the
decrease in the client's metabolism, resulting in slow motility of the gi tract. The
nurse should instruct the client to increase fiber and fluid intake to reduce the risk
for constipation.
,A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of
the following nonpharmacological interventions should the nurse suggest to the
client to reduce pain?
• Increase intake of foods containing calcium
• Alternate application of heat and cold to the affected joints
• Keep the affected extremities elevated
• Limit movement of the affected joints
• Alternate application of heat and cold to the affected joints
Rationale: the nurse should instruct the client to alternate heat and cold
applications to decrease joint inflammation and pain. The application of cold can
relieve joint swelling, and the application of heat can decrease joint stiffness and
pain.
A nurse is caring for a client who is receiving a blood transfusion. The client
becomes restless, dyspneic, and has crackles noted to the lung bases. Which of the
following actions should the nurse anticipate taking?
• Administer an antihistamine
• Slow the infusion rate
• Give the client a corticosteroid
• Elevate the client's lower extremities
• Slow the infusion rate
, Rationale: dyspnea, restlessness, and the onset of crackles during a blood
transfusion are manifestations of circulatory overload. The nurse should slow or
stop the infusion to improve the client's ability to breathe, place the client in an
upright position, and notify the provider. The provider might prescribe a diuretic to
alleviate the fluid overload.
A nurse in the emergency department is assessing a client who has a detached
retina. Which of the following should the nurse expect the client to report?
• "it's like a curtain closed over my eye."
• "this sharp pain in my eye started 2 hours ago."
• "i've been having more and more difficulty seeing over the last few weeks."
• "i seem to have more problems seeing different colors."
• "it's like a curtain closed over my eye."
Rationale: a retinal detachment is the separation of the retina from the epithelium.
It can occur because of trauma, cataract surgery, retinopathy, or uveitis. Clients
who have retinal detachment typically report the sensation of a curtain being pulled
over part of the visual field.
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?
• Add full-fat yogurt to the diet
• Add cabbage to the diet
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