PN Adult Medical Surgical 2023
ATI PN Adult Medical Surgical 2023
Total Questions : 70
Showing 10 questions Sign up for moreA nurse is reinforcing teaching about home safety measures with a client who is visually impaired. Which of the following instructions should the nurse include?
Explanation
A. Mark the edges of steps: Marking the edges of steps with high-contrast tape or paint helps increase visibility and prevent falls for individuals with visual impairments.
B. Use low-wattage light bulbs: Using low-wattage light bulbs might reduce the brightness needed for safety. Higher-wattage bulbs or bright, energy-efficient lighting is usually recommended to improve visibility.
C. Place throw rugs over electrical cords: Placing throw rugs over electrical cords can create tripping hazards and is not a safe practice for individuals with visual impairments.
D. Leave doors slightly ajar: Leaving doors ajar can create obstacles and increase the risk of injury for someone with visual impairment, as they may not be able to detect the open door.
A nurse is reinforcing discharge teaching with a client regarding self-administration of regular insulin. Which of the following instructions should the nurse include?
Explanation
A. Warm the insulin vial to dissolve any crystals that develop: Insulin should not be warmed as this can alter its efficacy. If crystals are present, the vial should be gently rolled, not heated.
B. Keep unopened insulin vials in the freezer: Insulin should not be kept in the freezer. Unopened vials should be stored in the refrigerator.
C. Store opened insulin vials at room temperature for up to 4 weeks: Opened insulin vials can be stored at room temperature for up to 4 weeks, which helps maintain its stability and usability.
D. Plan to eat a snack 6 hr after insulin administration: The timing of snacks should be aligned with insulin administration based on the type and dosage, not a fixed interval of 6 hours.
A nurse is caring for a client who has a tracheostomy. When providing tracheostomy care, which of the following actions should the nurse perform first?
Explanation
A. Change the dressing on the tracheostomy site: Although changing the dressing is an important part of tracheostomy care, it should be performed after ensuring that the airway is patent and clear. The priority is to maintain an open airway and prevent obstruction.
B. Suction the tracheostomy tube: Suctioning the tracheostomy tube should be performed first to clear any secretions or obstructions that could impair breathing. Ensuring the airway is clear is critical before proceeding with other care tasks.
C. Auscultate the client's lungs: While auscultation is important for assessing lung sounds and the overall respiratory status, it is secondary to ensuring the tracheostomy tube is clear. The priority is to address any potential airway obstructions first.
D. Clean the inner cannula: Cleaning the inner cannula is an essential part of tracheostomy care, but it should be done after ensuring the airway is clear and patent. Prioritizing suctioning ensures that the cannula can be cleaned effectively without interference from secretions.
A nurse is reinforcing teaching with a client who has angina. Which of the following statements by the client indicates an understanding of the teaching?
Explanation
A. "I will have hot, dry, and flushed skin if I am having a heart attack": This statement is incorrect as it does not accurately reflect typical symptoms of a heart attack. Common symptoms include chest pain, shortness of breath, and possibly cold sweat, not hot, dry, and flushed skin.
B. "I will wait 30 minutes before taking action if I have heartburn": Waiting 30 minutes before taking action is incorrect for angina or heartburn. Immediate action is required for angina symptoms, and heartburn should be differentiated from angina by a healthcare provider.
C. "I will notify emergency response if I have sudden jaw pain": This statement is correct because sudden jaw pain can be a symptom of angina or a heart attack, indicating that immediate medical attention is needed.
D. "I will take four nitroglycerin sublingual tablets if I have chest pain": This statement is incorrect as taking four nitroglycerin tablets is excessive and could be harmful. The standard recommendation is to take one tablet every 5 minutes for up to three doses if chest pain persists, and then seek medical attention.
A nurse is caring for a client who is in skeletal traction. Which of the following actions should the nurse take?
Explanation
A. Unscrew the pins to cleanse the pin sites: Unscrewing the pins is incorrect as it can compromise the stability of the traction and increase the risk of infection. Pin site care should be performed according to the facility's protocol without disturbing the pins.
B. Remove the weights while turning the client in bed: Removing weights is incorrect as it can disrupt the alignment and effectiveness of the traction. Weights should be left in place to maintain proper traction and alignment.
C. Loosen the rope knots holding the weights for 30 min if the client reports pain: Loosening the rope knots is inappropriate and can interfere with the traction's effectiveness. Pain management should involve assessing the client's comfort and reviewing the traction setup, but not altering the traction itself.
D. Ensure that there is at least 4.5 kg (10 lb) of weight applied to the client's traction: This is correct as maintaining the appropriate amount of weight is crucial for proper skeletal traction. Ensuring that the prescribed weight is applied helps in achieving the desired therapeutic effect.
A nurse is caring for a client who requires seizure precautions. Which of the following equipment should the nurse place at the client's bedside?
Explanation
A. A padded tongue blade: A padded tongue blade is not recommended as it can cause injury to both the client and the nurse. It is a common misconception that it should be used during a seizure, but it does not prevent injury.
B. Anticonvulsant medication: While important for managing seizures, anticonvulsant medication is not an equipment item to be placed at the bedside. It is typically administered as per the prescription and monitored by healthcare providers.
C. A nasogastric tube: A nasogastric tube is not relevant for seizure precautions and is used for different medical purposes, such as feeding or gastric decompression.
D. A suction machine: This is correct as a suction machine is essential to clear the airway in case of aspiration during or after a seizure. It helps in maintaining airway patency and preventing complications.
A nurse is reinforcing teaching with a client who is taking diltiazem sustained-release tablets for hypertension. Which of the following instructions should the nurse include?
Explanation
A. Store the medication in the refrigerator: Diltiazem sustained-release tablets do not need to be refrigerated; they should be stored at room temperature, away from moisture and heat.
B. Take the medication at mealtime: It is not necessary to take diltiazem with food unless specifically advised by a healthcare provider. Generally, it can be taken with or without food.
C. Drink grapefruit juice with the medication: Grapefruit juice should be avoided with diltiazem as it can increase the risk of adverse effects by altering the metabolism of the drug.
D. Swallow the medication whole: This is correct as sustained-release tablets should not be chewed or crushed. They are designed to release the medication slowly over time, which can be disrupted if the tablet is altered.
A nurse is reinforcing teaching with a client who has COPD and reports shortness of breath and little appetite. Which of the following instructions should the nurse include in the teaching?
Explanation
A. Eat lighter, low-calorie foods first: While light foods can be easier to consume, prioritizing low-calorie foods may not address the client's nutritional needs. The focus should be on high-calorie, high-protein foods to maintain weight and strength.
B. Limit fluid intake during meals: This is correct as limiting fluid intake during meals can help prevent bloating and early satiety, which can be an issue for clients with COPD who have reduced appetite.
C. Eliminate dairy products: There is no general indication to eliminate dairy products unless the client has a specific intolerance or allergy. Dairy products are not universally problematic for clients with COPD.
D. Consume three regular meals daily: Clients with COPD may benefit from smaller, more frequent meals rather than three large meals to prevent feelings of fullness that can reduce appetite and increase shortness of breath.
A nurse is reviewing the medical record of a client who has hypertension and a new prescription for propranolol. Which of the following findings should the nurse identify as a contraindication for taking propranolol?
Explanation
A. Glaucoma: Propranolol is not contraindicated in clients with glaucoma. It may, however, need to be used cautiously if the client has narrow-angle glaucoma due to potential systemic effects.
B. Asthma: This is correct as propranolol, a non-selective beta-blocker, can exacerbate asthma by causing bronchoconstriction, making it contraindicated in individuals with asthma.
C. Migraine headaches: Propranolol is often used to prevent migraine headaches and is not contraindicated in this condition. It is actually considered an effective treatment for migraine prophylaxis.
D. Irritable bowel syndrome: Propranolol is not contraindicated in irritable bowel syndrome. There are no specific concerns regarding propranolol's use with this condition.
A nurse is caring for a client who is receiving treatment for cancer and is experiencing stomatitis. Which of the following actions should the nurse take to help manage the condition?
Explanation
A. Discourage drinking with a straw: Drinking with a straw is not typically discouraged for stomatitis and may actually help the client avoid contact with painful areas in the mouth.
B. Recommend consumption of cold items: This is correct as cold items can provide soothing relief for the inflamed mucous membranes in stomatitis, helping to reduce discomfort.
C. Provide an alcohol-based mouthwash: Alcohol-based mouthwashes can irritate the mucous membranes further and should be avoided. Non-alcoholic, soothing mouthwashes or saline rinses are preferred.
D. Minimize the use of gravies and sauces: While gravies and sauces can be irritating due to their acidity or spiciness, the primary recommendation is to focus on soothing and non-irritating foods and oral care practices.
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