ATI MED SURG PROCTORED PRACTICE
26.A nurse in a provider's office is reinforcing teaching with a client who has anemia and has
been
taking ferrous gluconate for several weeks. Which of the following instructions should the nurse
include?
1) Take this medication between meals.
2) Limit intake of Vitamin C while taking this medication.
3) Take this medication with milk.
4) Limit intake of whole grains while taking this medication. - ANS-1
A nurse caring for a client at risk for increased intracranial pressure is monitoring the client for
manifestations that indicate that the pressure is increasing. To do this, the nurse should check
the function of the third cranial nerve by performing which of the following data-collection
activities?
1) Observing for facial asymmetry
2) Checking pupillary responses to light
3) Eliciting the gag reflex
4) Testing visual acuity - ANS-2
A nurse in a provider's office is collecting data for a 45-year-old client who is having
manifestations associated with perimenopause. Which of the following findings should the nurse
expect?
1) Report of urinary retention
2) Elevated blood pressure above 140/90
3) Report of dryness with vaginal intercourse
4) Elevated body temperature above 37.8Æ C (100Æ F) - ANS-3
A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge
resection of the left lung and has a chest tube to suction. Which of the following is the priority
finding the nurse should report to the provider?
1) Abdomen is distended
2) Chest tube drainage of 70 mL in the last hour
3) Subcutaneous emphysema is noted to the left chest wall
4) Pain level of 6 on a 0 to 10 scale - ANS-1
,A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood
cells. The client develops itching and hives. Which of the following actions should the nurse take
first?
1) Obtain vital signs.
2) Stop the transfusion.
3) Notify the registered nurse.
4) Administer diphenhydramine. - ANS-2
A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland.
Which of the following actions should the nurse include in the plan?
1) Position the client supine while in bed.
2) Change the nasal drip pad as needed.
3) Encourage frequent brushing of teeth.
4) Encourage the client to cough every 2 hr following surgery. - ANS-2
A nurse is assisting with caring for a client who has a new concussion following a motor-vehicle
crash. The nurse should monitor the client for which of the following manifestations of increased
intracranial pressure?
A nurse is assisting with planning an immunization clinic for older adult clients. Which of the
following information should the nurse plan to include about influenza?
1) Individuals at high risk should receive the live influenza vaccine.
2) Immunization for influenza should be repeated every 10 years.
3) The composition of the influenza vaccine changes yearly.
4) The influenza vaccine is necessary only for clients who have never had influenza. - ANS-3
A nurse is assisting with planning care for a client who is recovering from a left-hemispheric
stroke. Which of the following interventions should the nurse include in the plan?
1) Control impulsive behavior.
2) Compensate for left visual field deficits.
3) Re-establish communication.
4) Improve left-side motor function. - ANS-3
, A nurse is assisting with teaching a client who has a history of smoking about recognizing early
manifestations of laryngeal cancer. The nurse should instruct the client to monitor and report
which of the following manifestations of laryngeal cancer?
A nurse is assisting with the care of a client following a transurethral resection of the prostate
(TURP) and has an indwelling urinary catheter. Which of the following actions should the nurse
take?
1) Weigh the client weekly.
2) Irrigate the catheter as prescribed.
3) Instruct the client to report an urge to urinate.
4) Instruct the client to bear down as if to have a bowel movement every hour. - ANS-2
A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of
the following actions should the nurse take? (Select all that apply.)
1) Encourage fluid intake.
2) Monitor the puncture site for hematoma.
3) Insert a urinary catheter.
4) Elevate the client's head of bed.
5) Apply a cervical collar to the client. - ANS-1 2
A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction.
Which of the following actions should the nurse take?
1) Loosen the knots on the ropes if the client is experiencing pain.
2) Ensure the client's weights are hanging freely from the bed.
3) Check the client's bony prominences every 12 hr.
4) Cleanse the client's pin sites with povidone-iodine. - ANS-2
A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should
monitor the client for which of the following manifestations?
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