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Ati rn adult med Surg 2023
Total Questions : 44
Showing 10 questions, Sign in for moreA nurse in the emergency department is managing the care of a client who has an electrical shock injury. Which of the following actions should the nurse take first?
A nurse is assessing a client who is postoperative following a transurethral resection of the prostate and is receiving continuous bladder irrigation. The client reports bladder spasms, and the nurse notes a scant amount of fluid in the urinary drainage bag. Which of the following actions should the nurse take?
A nurse is assessing a client who has a urinary catheter. The nurse notes the client's IV tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse should identify that the client is at risk for which of the following conditions?
A nurse is caring for a client who is postoperative following an endoscopy with moderate (conscious) sedation. Which of the following assessment findings is the nurse's priority?
A nurse is providing instructions to a client who has primary syphilis. Which of the following instructions should the nurse include in the discharge plan?
A nurse is teaching the family of a client who has Alzheimer's disease about caring for the client at home. Which of the following instructions should the nurse include?
Cerebrovascular accident 2 years ago
Coronary artery disease
Hypertension
Hyperlipidemia
0800:
Client is alert and oriented to person, place, and time. Client reports headache. Pupils are equal and reactive at 3 mm. Hand grasps are strong and equal.
1200:
Client is restless, agitated, and unresponsive to verbal commands. Pupils are reactive at 5
mm. Client has vomited. Glasgow Coma Scale score 9.
0800:
Blood pressure 160/78 mm Hg Heart rate 98/min
Respiratory rate 20/min
Temperature 36.9°C (98.4° F)
Oxygen saturation 95% on 2 L/min via nasal cannula 1200:
Blood pressure 210/76 mm Hg Heart rate 120/min Respiratory rate 24/min Temperature 37.4° C (99.3° F)
Oxygen saturation 90% on 6 L/min via nasal cannula
A nurse is caring for a client.
A nurse is reviewing the client's medical record. After reviewing the medical record, which of the following actions should the nurse plan to take? For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.
Potential Prescription: Anticipated /Nonessential /Contraindicated
Explanation
A) Coughing is not directly related to the client's condition as described in the scenario.
B) Keeping the client's head in a midline position is anticipated to maintain an open airway and prevent further complications, particularly after a cerebrovascular accident.
C) Elevating the head of the bed is anticipated as it can help improve respiratory function and reduce intracranial pressure, which is beneficial given the client's history of cerebrovascular accident and current restlessness and agitation.
D) Assisting the client to the bathroom is contraindicated due to the client's current unresponsiveness and risk of falls; a bedpan or catheter may be more appropriate.
E) Initiating seizure precautions is anticipated because the client's Glasgow Coma Scale score indicates a decreased level of consciousness, which could predispose them to seizures, especially with a history of cerebrovascular accident.
F) Decreasing oxygen to 1.5 L/min via nasal cannula is contraindicated given the client's decreased oxygen saturation levels; instead, the nurse should anticipate the need to maintain or increase oxygen to ensure adequate tissue perfusion.
Blood pressure 106/64 mm Hg
Heart rate 95/min
Respiratory rate 20/min
Temperature 37.8° C (100° F)
Oxygen saturation 95% on O2 at 3 L/min via nasal cannula
WBC count 13,000/mm3 (5,000 to 10,000/mm2)
Urinalysis: leukoesterase, nitrites", WBC, RBC, Cloudy urine
Hct 50% (37% to 47%)
Potassium 4.8 mEq/L (3.5 to 5 mEq/L)
Sodium 148 mEq/L (136 to 145 mEq/L)
Oriented to person and place
Urinary incontinence
Facial flushing Poor skin turgor
Fatigue
Capillary refill greater than 3 seconds
Diminished lung sounds in bases
Dementia
Systemic lupus erythematosus
A nurse is caring for an older adult client who was admitted with a urinary tract infection.
Findings upon admission:
The nurse is assessing the client 12 hr later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition.
Explanation
A) An increase in oxygen saturation to 96% at a reduced oxygen flow rate indicates potential improvement in respiratory function, which can be a positive sign of recovery from a UTI.
B) Disorientation to person, place, and time suggests a potential worsening of the condition, as UTIs can cause confusion, especially in older adults and those with dementia.
C) A drop in blood pressure to 100/50 mm Hg could indicate potential worsening, as it may suggest dehydration or sepsis, both of which can complicate a UTI.
D) A decrease in hematocrit (Hct) to 45% is within the normal range and could indicate an improvement if previously elevated due to dehydration.
E) Pink-tinged urine may indicate the presence of blood, a sign of potential worsening, as it could suggest a more severe infection or other complications.
F) A butterfly rash is not typically associated with a UTI and may be unrelated to the current diagnosis; in this scenario it is related to the patient’s history of systemic lupus erythematosus.
Hemochromatosis
Heart rate 125/min
Respiratory rate 26/min
Blood pressure 92/65 mm Hg
Temperature 37.2° C (99° F)
Oxygen saturation 94% on room air
Jaundice
Orange-brown colored urine
Positive hemoccult blood
Abdominal distention
Lethargy
1+ edema
Oriented x4
Tachydysrhythmia
Dyspnea with exertion
Albumin 3.3 g/dl. (3.5 to 5 g/dL)
Iron 250 mcg/dL (60 to 180 mcg/dL)
Hgb 9.5g/dL (12 to 18 g/dL)
Bilirubin 2.0 mg/dl. (0.3 to 1 mg/dL)
Prothrombin time 12.5 seconds (11 to 12.5 seconds)
A nurse is admitting a middle adult client who has cirrhosis.
Findings upon admission:
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?
For each finding, click to specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition.
Findings 24 hr Later: Unrelated to Diagnosis /Indication of Potential Worsening/Indication of Potential Improvement Condition
Explanation
A) Elevated iron levels are directly related to hemochromatosis and could indicate a worsening condition if they continue to rise, as this condition causes iron to accumulate in the body, leading to further liver damage.
B) An increased albumin level could be a sign of potential improvement, as low albumin levels are common in liver disease due to the liver's reduced ability to synthesize proteins.
C) A productive cough may be unrelated to the diagnosis of cirrhosis but could be indicative of an additional respiratory issue that needs to be addressed.
D) Ascites, the accumulation of fluid in the abdomen, is a common complication of cirrhosis and would suggest a potential worsening of the condition.
E) Hematemesis is a serious symptom often associated with advanced liver disease and significant bleeding in the gastrointestinal tract, indicating a potential worsening of the patient's condition.
F) Spontaneous bruising can occur due to decreased production of clotting factors by the liver, also suggesting a worsening condition.
A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft?
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