RN 2023 Adult Medical Surgical ATI Proctored
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C. Thinning of the skin
A nurse is caring for a client who
has atopic dermatitis and a prescription Thinning of the skin and delayed healing
for triamcinolone ointment. The nurse are adverse effects of topical glucocorti-
should assess the client to monitor for coid
which of the following adverse effects? preparations. The client should only ap-
ply the ointment to dry patches of the skin
A. Increased pigmentation because
B. Localized hair loss topical steroids can cause atrophy of the
C. Thinning of the skin dermis and epidermis, which can result
D. Increased sensitivity to the sun in thinning
of the skin.
D. Frothy sputum
A nurse is assessing a client who has The nurse should identify that frothy spu-
left-sided heart failure. Which of the fol- tum, dyspnea, and wheezing are mani-
lowing findings should the nurse identify festations of
as a manifestation of left-sided heart fail- left-sided heart failure. Treatment in-
ure? cludes fluid restriction and diuretics to
decrease
A. Dependent edema preload and reduce pulmonary conges-
B. Jugular distention tion. Pink-tinged frothy sputum can be
C. Weight gain an early indication of pulmonary edema
D. Frothy sputum and can be life-threatening. Therefore,
the nurse should
notify the provider immediately.
A nurse is caring for a client who is ex-
periencing anxiety as well as numbness
and tingling of the lips and fingers. The A. Respiratory alkalosis
client's ABGs are: pH 7.48, PCO2 30 mm
Hg, HCO3- 24 mEq/L, PaO2 85 mm Hg. This pH is alkaline (increased) and the
Which of the following acid-base imbal- PCO2 is decreased, representing alveo-
ances should the nurse identify that the lar
client is experiencing? hyperventilation and resultant respirato-
ry alkalosis.
A. Respiratory alkalosis
B. Metabolic alkalosis
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C. Respiratory acidosis
D. Metabolic acidosis
A nurse is assessing a client who has
B. Osteoporosis
Cushing's syndrome. Which of the follow-
ing findings should the nurse expect?
Osteoporosis is a common finding with
Cushing's syndrome. Bones become
A. Vitiligo
thinner as a
B. Osteoporosis
result of mineral loss and nitrogen deple-
C. Myxedema
tion, and the risk for fractures increases.
D. Heat intolerance
A nurse is inspecting the skin of a client
who has basal cell carcinoma. The nurse A. A pearly, waxy nodule
should identify which of the following le-
sion characteristics on the client's skin? A client who has basal cell carcinoma
has a nodular lesion with well-defined
A. A pearly, waxy nodule borders and a
B. An irregular border on a variegat- pearly or waxy appearance, resulting
ed-colored lesion from overexposure to the sun, especially
C. A firm, nodular, crusty, or ulcerated on the face,
lesion head, and neck.
D. A weeping vesicle
A is correct.
The nurse should tap the client's cheek
just in front of the ear and below the
zygomatic arch. The client who has
A nurse is assessing a client who has hypocalcemia will display a Ckvostek's
hypocalcemia. In which of the follow- sign, which is a
ing areas should the nurse tap on the twitching of the facial muscle.
client's face to detect the presence of
Chvostek's sign?
A nurse in an emergency department is
assessing a client who is overusing pre-
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scribed diuretics and has a sodium level B. Low urine specific gravity
of 127 mEq/L. Which of the following lab-
oratory findings should the A client who has hyponatremia as a re-
nurse expect? sult of diuretic overuse has a low urine
specific
A. High lipase gravity. The increased excretion of wa-
B. Low urine specific gravity ter alters the ratio of particulate matter,
C. Low hemoglobin which
D. High creatine kinase-MB (CK-MB) affects the specific gravity.
A home health nurse is assisting a client
with planning care for a family mem-
ber who has Alzheimer's disease. Which A. Remove clutter from rooms and hall-
of the following instructions should the ways.
nurse include?
The nurse should instruct the family
A. Remove clutter from rooms and hall- member to remove clutter from rooms
ways. and hallways so the client is able to walk
B. Place a monthly calendar in the without the risk of falling or tripping over
client's room. objects. Later in the disease, the client
C. Use confrontation to manage the can experience seizures, so cluttered ar-
client's behavior. eas could be a risk to the client.
D. Review the daily schedule with the
client every morning.
C. Refractory hypoxemia
ARDS is a systemic inflammatory re-
A nurse is caring for a client who has de-
sponse to trauma, sepsis, burns, pancre-
veloped acute respiratory distress syn-
atitis, and blood
drome (ARDS). Which of the following
transfusions, when excess lung fluid di-
findings should the nurse identify as a
lutes surfactant activity in the lungs. A
manifestation of this syndrome?
client who
has ARDS has refractory hypoxemia,
A. An audible pleural friction rub
which is hypoxemia that does not im-
B. Tracheal deviation from the midline
prove with
C. Refractory hypoxemia
oxygen therapy. Extensive pulmonary
D. Bloody expectorant when coughing
edema evident on a chest x-ray is a man-
ifestation of
ARDS.
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An emergency room nurse is assessing C. Use of accessory muscles
a client who has asthma and difficulty
breathing. Which of the following find- A client who has status asthmaticus
ings should indicate to the nurse that the uses accessory muscles to help facilitate
client is experiencing status asthmati- breathing,
cus? which is a manifestation of a se-
vere airflow obstruction. The situation
A. Coughing is life-threatening and the nurse should
B. Flat neck veins intervene immediately with strong sys-
C. Use of accessory muscles temic bronchodilators, epinephrine, cor-
D. Presence of coarse crackles ticosteroids, and oxygen.
D. Skin rash
A nurse is teaching a client who has a
new prescription for phenytoin to treat a
When using the urgent vs. non-urgent
seizure disorder. Which of the following
approach to client care, the nurse should
adverse effects should the nurse instruct
determine
the client to report immediately to the
that the priority finding is a rash, which
provider?
can have a measles-like appearance and
progress
A. Tender, bleeding gums
to exfoliative dermatitis or Stevens-John-
B. Increased facial hair
son syndrome. The client should report
C. Constipation
this finding
D. Skin rash
to the provider immediately.
A nurse is monitoring a client following
a lumbar laminectomy. The client has
a drain and indwelling urinary catheter.
B. Clear drainage on the dressings
The nurse should identify which of the
following findings as an indication of a
The nurse should identify clear drainage
complication of the surgery?
on or around the dressing as an indica-
tion of a
A. Oral temperature of 37.2° C (99° F)
cerebral spinal leak and should report
B. Clear drainage on the dressings
this finding to the provider immediately.
C. Drain output 75 mL in 4 hr
D. Decreased bowel sounds in all quad-
rants of the abdomen
C. Increased abdominal girth
A nurse is assessing a client who has
right-sided heart failure. Which of the fol-
Increased abdominal girth is an expect-
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