MED SURG ATI QUESTIONS AND ANSWERS LATEST UPDATED 2024/2025 WITH CORRECT VERIFIED ANSWERS, Exams of Nursing

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UPDATED 2024/2025 WITH CORRECT VERIFIED

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Which of the following clients have an increased risk for developing pneumonia? (Select all that apply) A. Client who has dysphagia B. Client who has AIDS C. Client who was vaccinated for pneumococcus and influenza 6 months ago D. Client who is postoperative and has received local anesthesia E. Client who has a closed head injury and is receiving ventilation F. Client who has myasthenia gravis - CORRECT ANSWERS A, B, E, F Difficulty swallowing, immunocompromised, invasive procedure, and difficulty clearing secretions A nurse in the ED is caring for a client who was admit with an acute asthma attack. Which of the following indicates the client's respiratory status is declining? (Select all that apply) A. SaO2 95% B. Wheezing C. Retraction sternal muscles D. Pink mucous membranes E. Premature ventricular complexes (PVCs) - CORRECT ANSWERS B, C, E The nurse is providing care to a patient newly admitted with bacterial pneumonia. Which action should the nurse perform first? A. Apply oxygen per nasal cannula at 5 L/min as prescribed B. Obtain a sputum specimen for culture and sensitivity C. Provide a meal for diet as tolerated D. Insert an IV catheter and start the prescribed antibiotic - CORRECT ANSWERS A. Adequate oxygenation is a priority for all patients. The nurse should apply the prescribed amount of oxygen to the patient first. The sputum specimen should be obtained before beginning the prescribed antibiotic. The meal tray would be of the least priority.

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A nurse is assessing a client who has experienced a gun shot wound. Findings include BP 108/55, HR 124/min, RR 36/min, temperature 38.6 (101.4), and SaO2 95% on oxygen 15L/min via non- rebreather mask. The client reports dyspnea and pain. The nurse reassess the client 30 minutes later. Which of the following should the nurse report to the provider? (Select all that apply) A. Distended neck veins B. Tracheal deviation C. Headache D. Nausea E. HR 154/min - CORRECT ANSWERS A, B, E Distended neck veins indicate that the client's condition is worsening; they are due to impaired gas exchange, which compresses the blood vessels and limits blood return. Tracheal deviation is due to altered intrathoracic pressure, which moves the trachea toward the unaffected side An increased HR is due to impaired cardiac output as a result of trauma The nurse identifies nursing diagnoses that are appropriate for a patient with an acute asthma attack. Which diagnosis is of the highest priority? A. Ineffective Health Maintenance related to lack of knowledge about attack triggers and appropriate f medications B. Ineffective breathing pattern related to anxiety C. Ineffective airway clearance related to bronchoconstriction and increased mucous production D. Anxiety related to difficulty breathing - CORRECT ANSWERS C. Ineffective airway clearance is the highest priority. Bronchospasm and bronchoconstriction, increased mucous secretion, and airway edema narrow the airways and impair airflow during an acute attack of asthma. Both inspiratory and expiratory volumes are affected, decreasing the oxygen available at the alveolus for the process of respiration. Narrowed air passages increase the work of breathing, increasing the metabolic rate and tissue demand for oxygen. The diagnoses that address anxiety, ineffective breathing pattern, and

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ineffective health maintenance are important and can be focused on after the patient's ineffective airway clearance is addressed. A nurse is caring for several clients. Which of the following clients are at risk for having a pulmonary embolism? (Select all that apply) A. A client who has a BMI of 30 B. A female client who has postmenopausal C. A client who has a fractured femur D. A client who is a marathon runner E. A client who has chronic atrial fibrillation - CORRECT ANSWERS A, C, E Obesity, a long bone fracture, and turbulent blood flow in the heart increase the risk for a blood clot A nurse is orienting a newly licensed nurse on the care of a client who is receiving hemodynamic monitoring. Which of the following statements by the newly licensed nurse indicates the teaching was effective? A. "Air should be instilled into the monitoring system." B. "The client should be in the prone position." C. "The transducer should be level with the 2nd intercostal space" D. "A chest X-ray is needed to verify placement." - CORRECT ANSWERS D. A chest x-ray is obtained to confirm proper placement of the lines A nurse is screening a client for hypertension. Which of the following actions by the client increase his risk for hypertension? - CORRECT ANSWERS - Eating popcorn at the movie theater

• Consuming 36 oz of beer daily A nurse is caring for a client who received a bolus dose of succinylcholine (Anectine) IV before an endoscopy procedure. During the procedure, the client suddenly develops rigidity, and his body

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temperature begins to rise. The nurse should anticipate a prescription for which of the following medications? A. A second dose of succinylcholine (Anectine) B. Naloxone as an antagonist at receptor sites C. Dantrolene (Dantrium) to slow metabolic activity of muscles D. Vecuronium (Norcuron) as an adjunct to muscle relaxation - CORRECT ANSWERS C. Dantrolene acts on skeletal muscles to reduce metabolic activity A nurse in the emergency department is assessing a client who was in a motor vehicle crash. Findings include absent breath in the left lower lobe with dyspnea, blood pressure 118/68, HR 124/min, RR 38/min, temp 38.6 (101.4), and SaO2 92% on room air. Which of the following actions should the nurse take first? A. Obtain a chest x ray B. Prepare for chest tube insertion C. Administer oxygen via a high flow mask D. Initiate IV access - CORRECT ANSWERS C. According to ABCs, administering oxygen via high flow mask is priority. A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the following are expected findings? (select all that apply) A. Impulse control difficulty B. Left hemiplegia C. Loss of Depth perception D. Aphasia E. Lack of awareness - CORRECT ANSWERS A B C E

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A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take? A. Position the client in an upright position, leaning over the bedside table B. Explain the procedure to the client C. Obtain ABGs from the client D. Administer benzocaine pray to the client - CORRECT ANSWERS A. Positioning the client in an upright position and bent over the bedside table widens the pleural space for the provider to access the pleural fluid A nurse preparing to care for a client following chest tube placement. Which of the following items should be available in the client's room? (Select all that apply) A. Oxygen B. Sterile water C. Enclosed hemostat clamps D. Indwelling urinary catheter E. Occlusive dressing - CORRECT ANSWERS A, B, C, E Oxygen should be readily available in case the client develops respiratory distress following chest tube placement. If the chest tube becomes disconnected, the end of the tubing should be placed in sterile water to restore the water seal Hemostat clamps should be available for the nurse to use to check air leaks Immediately place an occlusive dressing over the chest tube insertion site if becomes disconnected. This allows air to escape and reduces the risk for a tension pneumothorax

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A nurse is orienting a newly licensed nurse who is caring for a client that is receiving mechanical ventilation, which has been placed on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse demonstrates an understanding of PSV? A. It keep the alveoli open and prevents atelectasis B. It permits spontaneous ventilation to decrease the work of breathing C. It is used with clients who have difficulty weaning from the ventilator D. It delivers a preset ventilatory rate and tidal volume to the client - CORRECT ANSWERS B. PSV maintains a preset amount of pressure during spontaneous ventilation to decrease the work of breathing The nurse assesses the wound of a client burned as a result of stepping into a bathtub filled with very hot water. Which assessment finding of the burned areas on the tops of both feet does the nurse use as a basis to document a probable full-thickness injury? A. Most of the wounded area is red B. The client reports that the area hurts when touched C. The area does not blanch when firm pressure is applied D. Thrombosed blood vessels are visible beneath the skin surface - CORRECT ANSWERS D. A patient is admitted to the emergency department with a cervical SCI following an automobile crash. What should the nurse explain to the family as the reason for the patient being placed on mechanical ventilation?

1. The accident injured the patient's lungs
2. The nerves that control lung function have been injured
3. The patient is unable to breathe because of being unconscious
4. The ventilator is temporary to ensure the patient receives adequate oxygen until recovery - CORRECT ANSWERS 2 The nurse is assessing the breathing pattern of a patient with a head injury who has a change in level of consciousness. Which pathophysiologic event causes an irregular respiratory pattern as level of consciousness decreases?

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1. Pressure on the meninges
2. Reflexive motor responses
3. Loss of the oculocephalic reflex
4. Brainstem responses to changes in PaCO2 - CORRECT ANSWERS 4 The nurse notes that a patient with a systemic illness is not demonstrating signs of neurologic involvement. Which physiologic mechanism should the nurse recall that protects the brain from harmful substances?
5. Blood-brain barrier
6. Structure of neurons
7. Large oxygen demand
8. Circulation of cerebrospinal fluid - CORRECT ANSWERS 1. To prevent infection when infusing an intermittent "piggyback" IV line, which intervention does the nurse implement? A. Detaching and capping the secondary line after use B Backpriming the secondary container from the primary line C. Using a new secondary container with each drug infused D. Using sterile gloves when administering medication - CORRECT ANSWERS B. A patient is admitted to the emergency department with hypovolemia. Which IV solution should the nurse anticipate administering?
9. 3% sodium chloride
10. 10% dextrose in water
11. 0.45% sodium chloride
12. lactated Ringer's solution - CORRECT ANSWERS 4. Ringer's solution is an isotonic, balanced electrolyte solution that can expand plasma volume and help restore electrolyte balance.

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3% NaCl - hypertonic 0.45% NaCl - maintenance soln 10% dextrose - hypertonic During an assessment the nurse learns that a patient has had lower back pain for 9 months. For which type of pain will the nurse plan care? A. Chronic pain B. Somatic pain C. Visceral pain D. Neuropathic pain - CORRECT ANSWERS A. Chronic pain is defined as pain that has persisted long after the reason for the pain has healed or subsided. Low back pain is the most common cause of chronic pain. Somatic pain arises from nerve receptors originating in the skin, subcutaneous tissues, or deep body structures such as periosteum, muscles, tendons, joints, and blood vessels. Somatic pain may be either sharp and well localized, or dull and diffuse. Visceral pain arises from body organs and is dull and poorly localized because of the low number of nociceptors. Visceral pain may be described as deep cramping, splitting or stabbing pain, intermittent pain, or colicky pain. Neuropathic pain is the result of hyperactive nociceptive stimulation. Neuropathic pain may be acute, is usually chronic, and is associated with conditions such as diabetic neuropathy or postherpetic neuralgia. This pain is described as gnawing, electric shock-like, burning, shooting, or tingling. A nurse is caring for a client admitted to the hospital with respiratory difficulty after being diagnosed with ALS approximately 1 year ago. Which of the following client findings should the nurse anticipate? (Select all that apply) A. Loss of sensation B. Fluctuations in blood pressure C. Incontinence D. Ineffective cough E. Loss of cognitive function - CORRECT ANSWERS C, D Incontinence and ineffective cough from muscle weakness is a finding in a patient with ALS

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Which manifestation should the nurse expect to assess in a patient with fluid volume deficit?

1. Headache and muscle cramps
2. Dyspnea and respiratory crackles
3. Increased pulse rate and blood pressure
4. Orthostatic hypotension and flat neck veins - CORRECT ANSWERS 4. In fluid volume deficit, there is less volume in the vascular system, which decreases venous return and cardiac output, leading to manifestations of dizziness, orthostatic hypotension, and flat neck veins. A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? A. Teach the client to scan to the right to see objects on the right side of her body. B. Place the client's bedside table on the right side of the bed. C. Orient the client to the food on her plate using the clock method. D. Place the client's wheelchair on her left side. - CORRECT ANSWERS B A nurse is assessing a client who is in respiratory distress. The nurse should recognize that which of the following can cause a low pulse oximetry reading? (Select all that apply) A. Nail polish B. Inadequate peripheral circulation C. Hyperthermia D. Increased Hgb level E. Edema - CORRECT ANSWERS A, B, E Nail polish can affect the accuracy of pulse oximetry and result in an incorrect pulse oximetry level Inadequate peripheral circulation can result in a low reading while obtaining client's pulse oximetry level

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Edema can result in a low reading while obtaining a client's pulse oximetry level A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the client's chest tube was accidentally removed. Which of the following actions should the nurse take first? A. Place the tubing in sterile water to restore the water seal B. Apply sterile gauze to the insertion site C. Place tape around the insertion site D. Assess the client's respiratory status - CORRECT ANSWERS B. Using ABC priority framework, the application of a sterile gauze to the site should be the first action for the nurse to take. This allows the air to escape and reduces the risk of the tension pneumothorax A nurse is caring for a client who is experiencing respiratory distress. Which of the following are early clinical manifestations of hypoxemia? (Select all that apply) A. Confusion B. Pale skin C. Bradycardia D. Hypotension E. Elevated blood pressure - CORRECT ANSWERS B, E Pale skin and elevated blood pressure are early clinical manifestations of hypoxemia Which assessment does the nurse perform first on the client just admitted after an electrical injury with contact sites on the left hand and left foot? A. Core body temperature B. Electrocardiography C. Depth of burn injury

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D. Urine Output - CORRECT ANSWERS B. The nurse is planning care for a patient with an acute SCI. According to best practices, which medications should the nurse prepare to administer to this patient? (Select all that apply)

1. Analgesics
2. Antibiotics
3. Vasopressors
4. Antihistamines
5. Corticosteroids - CORRECT ANSWERS 1, 3, 5 The nurse assesses a depressed gag reflex in an unconscious patient. Which nursing diagnosis should the nurse use to guide this patient's care?
6. Risk for aspiration
7. Ineffective breathing pattern
8. Decreased intracranial adaptive capacity
9. Imbalanced nutrition: less than body requirements - CORRECT ANSWERS 1 The nurse is assessing a patient with damage to the lower motor neurons. Which findings should the nurse expect to assess in this patient? (Select all that apply)
10. loss of reflexes
11. increased muscle tone
12. decreased coordination
13. decreased muscle strength
14. muscle atrophy and fasciculations - CORRECT ANSWERS 1, 5 A nurse is caring for a client during surgery. The client has been administered dantrolene to treat malignant hyperthermia, and the administration of succinylcholine and other anesthetics has been discontinued. Which of the following additional actions should the nurse take? (Select all that apply)

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A. Place a cooling blanket on the client B. Administer oxygen at 100% C. Administer iced 0.9% NS D. Administer potassium chloride IV E. Monitor core body temperature - CORRECT ANSWERS A, B, C, E A patient has a peripherally inserted central catheter (PICC) line placed by an advanced practice nurse at the bedside. Before using the catheter, how is its placement verified? A. The physician who ordered the PICC insertion procedure verifies placement B. The line is slowly flushed with 10 ml of saline while the nurse notes the east of flow. C. A chest x ray is taken which shows the catheter tip in the lower superior vena cava D. The line is aspirated gently and the nurse watches for blood return - CORRECT ANSWERS C. A nurse in a clinic is caring for a client who was brought to the clinic by her partner. The partner states that the client woke up this morning, did not recognize him, and did not know where she was. The client reports chills and chest pain that is worse upon inspiration. Which of the following is the priority nursing action? A. Obtain baseline vital signs and oxygen saturation B. Obtain a sputum culture C. Obtain a complete history from the client D. Provide a pneumococcal vaccination - CORRECT ANSWERS A. Assessment is the first step of the nursing process and is essential to patient centered care The nurse notes that a patient with bacterial pneumonia has an overall gray skin tone with a bluish tinge around the lips. In which order should the nurse provide the listed interventions? Notify the healthcare provider. Start oxygen.

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Raise the head of the bed. Assess breath sounds. Obtain oxygen saturation level. - CORRECT ANSWERS Start oxygen. Raise the head of the bed. Obtain oxygen saturation level. Assess breath sounds. Notify the healthcare provider. Overall gray skin color and bluish tinge to lips indicate hypoxemia; supplemental oxygen is highest priority. Second, raise the head of the bed to promote chest expansion and alveolar ventilation. Assessment of oxygen saturation and breath sounds can be completed next. The physician should be contacted after the patient is receiving oxygen and assessments are completed. *A nurse is teaching a client who has ALS about a new prescription for riluzole (Rilutek). Which of the following instructions should the nurse give the client? A. Take this medication immediately prior to eating B. Drink a glass of milk with the medication C. Avoid consuming alcoholic beverages D. Monitor your blood pressure daily - CORRECT ANSWERS C. Riluzole is hepatotoxic, o alcoholic beverages should be avoided to decrease the risk of liver damage A nurse is reviewing the prescriptions for a client who has pneumothorax. Which of the following actions should the nurse perform first? A. Assess the client's pain B. Obtain a large-bore IV needle for decompression C. Administer lorazepam (Ativan) D. Prepare for chest tube insertion - CORRECT ANSWERS B. According to ABCs, establishing and maintaining the client's respiratory function is the priority. Therefore, obtaining a large-bore needle for decompression is the priority action by the nurse.

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A nurse working on a medical-surgical unit admits a client. Two hours after admission, the client's SaO2 is 91% and he is exhibiting audible wheezes and use of his accessory muscles. Which of the following medications should the nurse expect to administer? A. Antibiotic B. Beta-blocker C. Antiviral D. Beta 2 agonist - CORRECT ANSWERS D. A beta 2 agonist should be given to relive the client's symptoms A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium (Norcuron) to a client who has acute respiratory distress syndrome. Which of the following statements by the newly licensed nurse indicates understanding of the teaching? A. This medication is given to treat infection B. This medication is given to facilitate ventilation C. This medication is given to decrease inflammation D. This medication is given to reduce anxiety - CORRECT ANSWERS B. Vecuronium is a neuromuscular blocking agent given to facilitate ventilation and decrease oxygen consumption A patient who smashed a finger in the car door relates that the pain initially was sharp, but now it is dull and throbbing. What should the nurse recall as the reason for the current type of pain that the patient is experiencing? A. It is an example of the gate theory of pain transmission B. Indicates that the injury is less severe than initially perceived C. Transmission of pain stimuli via unmyelinated C fibers D. It is the result of interpretation of the pain stimulus by the thalamus - CORRECT ANSWERS C. Initial or "fast" pain is sharp and well defined because the stimulus is transmitted along myelinated A delta fibers to the thalamus and cerebral cortex. The smaller unmyelinated C fibers transmit the stimulus more slowly, producing a second or "slow" pain that is less well localized, dull, and throbbing. The gate-control theory of pain is a base for further research about pain-modulating systems. The change from acute sharp pain to dull throbbing pain does not indicate that the injury is less severe than initially perceived.

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A nurse is caring for a client who is admitted to the emergency department with a blood pressure of 266/147 mm Hg. The client reports a headache and states that she is seeing double. The client states that she ran out of her diltiazem (Cardizem) 3 days ago, and she has not been able to purchase more. Which of the following nursing interventions should the nurse expect to perform first? - CORRECT ANSWERS Administer acetaminophen for headache The nurse caring for a patient with asthma notices that the patient's respirations have slowed and coughing has stopped. Breath sounds are diminished throughout his lung fields and absent in the bases. Which action should the nurse take? A. Obtain a chest x ray B. Ask family members to leave C. Notify the healthcare provider D. Allow the patient to rest undisturbed - CORRECT ANSWERS C. Respiratory status can change rapidly during an acute asthma attack and its treatment. Slowed, shallow respirations with significantly diminished breath sounds and decreased wheezing may indicate exhaustion and impending respiratory failure. Immediate intervention is necessary so the healthcare provider needs to be notified. The healthcare provider might prescribe a chest x-ray. Asking the family members to leave is not a priority. Allowing the patient to rest undisturbed could eventually lead to respiratory arrest. A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states that she is anxious because she feels that she cannot get enough air. Vital signs are: HR 117/min, RR 38/min, temp 38.4 (101.2), BP 100/54. Which of the following actions is the priority action at this time? A. Notify the provider B. Administer heparin via IV infusion C. Administer oxygen therapy D. Obtain a spiral CT scan - CORRECT ANSWERS C. Meeting the oxygenation needs first is the priority action according to ABCs

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A nurse is caring for a client following a coronary artery bypass graft (CABG). Hemodynamic monitoring has been initiated. Which of the following actions by the nurse facilitate correct monitoring readings? (Select all that apply) A. Place the client in high-Fowler's position B. Level transducer to phlebostatic axis C. Zero transducer to room air D. Observe trends in readings E. Compare readings to physical assessment - CORRECT ANSWERS B, C, D, E B. The level of the transducer should be at the phlebostatic axis (right atrium) to ensure an accurate reading is obtained C. The transducer is zeroed to room air to ensure an accurate reading is obtained. Hemodynamic pressure lines should be calibrated to read atmospheric pressure as zero. D. The trend of the client's pressure reading assists in providing appropriate medical treatment E. Readings are compared to the client's physical assessment findings to evaluate the client's condition and the appropriate treatment provided. A nurse is planning care for a client who has dysphagia and has a new dietary prescription. Which of the following should the nurse include in the plan of care? (select all that apply) A. Have a suction equipment available for use B. Use thickened liquids. C. Place food on the client's unaffected side of her mouth. D. Assign an assistive personnel to feed the client slowly. E. Teach the client to swallow with her neck flexed. - CORRECT ANSWERS A B C E A nurse is assessing a client following a bronchoscopy. Which of the following findings should the nurse report to the provider? A. Blood-tinged sputum B. Dry, nonproductive cough

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C. Sore throat D. Bronchospasms - CORRECT ANSWERS D. Bronchospasms can indicate the client is having difficulty maintaining a patent airway. The nurse should notify the provider immediately A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? (Select all that apply) A. Continuous bubbling in the water seal chamber B. Gentle constant bubbling in the suction control chamber C. Rise and fall in the level of water in the water seal chamber with inspiration D. Exposed sutures without dressing E. Drainage system upright at chest level - CORRECT ANSWERS B, C Gentle bubbling in the suction control chamber is an expected finding as air is being removed A rise and fall of the fluid level in the water seal chamber upon inspiration and expiration indicate that the drainage system is functioning properly A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via a endotracheal tube. Which of the following should the nurse include in the teaching? A. Apply a vest restraint if self-extubation is attempted B. Monitor ventilator settings every 8 hours C. Document tube placement in centimeters at the angle of jaw D. Assess breath sounds every 1 to 2 hours - CORRECT ANSWERS D. The nurse should assess the breath sounds of a client on mechanical ventilation every 1-2 hours The client who tripped while carrying an open kettle o hot water received scald burns to the entire chest, the entire anterior section of the right arm, the right half of the abdomen, and the anterior

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portion of the right left from the groin to the knee. At what percentage of total body surface area does the nurse calculate the injury using the rule of nines? A. 22-23% B. 30-31% C. 39-40% D. 48-49% - CORRECT ANSWERS A. The RN is preparing to flush a PICC line.The protocol specifies using 50 units of heparin. Available is a multipdose vial containing heparin 10units/mL. Which syringe does the nurse use to draw up and administer heparin? A. 2 mL syringe B. 3 mL syringe C. 5 mL syringe D. 10 mL syringe - CORRECT ANSWERS D. Even though the RN only needs to draw up 5mL of heparin, using a 10 mL syringe lowers the pressure on the catheter and decreases the chances of blowing the line. A patient with a thoracic spinal cord injury is experiencing spinal shock. How should the nurse explain this pathophysiologic process to the patient?

1. There is damage to the lower motor neurons
2. There is an exaggerated sympathetic response
3. There is a loss of control of cardiovascular mechanisms
4. There is a temporary loss of reflex function below the level of injury - CORRECT ANSWERS 3 The nurse is caring for a patient with increased intracranial pressure. Why should the nurse expect osmotic diuretics to be prescribed for this patient?
5. To treat hyperthermia
6. To prevent the onset of seizures

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3. To reduce the risk for gastrointestinal hemorrhage
4. To draw edematous fluid into the vascular system - CORRECT ANSWERS 4 The nurse is preparing a teaching session on the neurologic system for a group of nursing students. What should the nurse include about the purpose and function of cerebrospinal fluid? (Select all that apply)
5. Cushions the brain
6. Helps nourish the brain
7. Prevents glucose from entering brain cells
8. Protects the brain and spinal cord from trauma
9. Removes waste products of cellular metabolism - CORRECT ANSWERS 1, 2, 4, 5 A nurse is teaching a client who has begun taking oral baclofen (Liresal) three times daily to treat muscle spasms caused by a spinal cord injury. Which of the following statements by the client indicates a need for further teaching? A. I will stop taking this medication right away if I develop dizziness B. I know the doctor will gradually increase my dose of medication for awhile C. I'll make sure that I empty my bladder completely while taking this medication D. I won't be able to drink alcohol while I'm taking this medication - CORRECT ANSWERS A. Abrupt withdrawal from baclofen can result in a number of adverse effects including visu hallucinations and seizures A nurse is caring for a client who has pneumonia. Assessment findings include temperature 37.8 ( F), respirations 30/min, BP 130/76, HR 100/min, and SaO2 91% on room air. Using a scale of 1 to 4, with 1 being the highest priority, prioritize the following nursing intervention: A. Administer antibiotics as prescribed B. Administer oxygen therapy C. Perform a sputum culture D. Administer an antipyretic medication to promote client comfort - CORRECT ANSWERS B

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C

A

D

The nurse is planning care for a patient with acute hypernatremia. What should the nurse include in this patient's plan of care? (Select all that apply)

1. Maintain IV access
2. Limit length of visits
3. Restrict fluids to 1500 mL per day
4. Conduct frequent neurologic checks
5. Orient to time, place, and person every 2 hours. - CORRECT ANSWERS 1, 4, 5 Frequent neurologic checks are necessary as hypernatremia draws water out of brain cells, causing them to shrink. As the brain shrinks, tension is placed on cerebral vessels, which may cause them to tear and bleed. Hypernatremia affects mental status and brain function including orientation to time, place, and person. Fluid replacement is the primary treatment for hypernatremia. A nurse is completing discharge teaching with a client who has a new prescription for prednisone (Deltasone) for asthma. Which of the following client's statements indicates a need for further teaching? A. I will drink plenty of fluids while taking this medication B. I will tell the doctor if I have black, tarry stools C. I will take my medication on an empty stomach D. I will monitor my mouth for canker sores - CORRECT ANSWERS C. The client should take this medication with food. Taking prednisone on an empty stomach can cause GI distress *A nurse is caring for a client who has myasthenia gravis (MG) and has developed drooping eyelids. Which of the following actions should the nurse take? (Select all that apply) A. Apply lubricating eye drops

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B. Encourage use of sunglasses C. port the head with pillows D. Tape eyes closed at night E. Provide for periods of rest during the day - CORRECT ANSWERS A, D Lubricating eye drops reduce corneal dryness and irritation caused by weakness of the eyelids Taping the eyes closed prevents corneal dryness A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome (ARDS)? (Select all that apply) A. A client who experienced a near-drowning incident B. A client following coronary artery bypass graft surgery C. A client who has a hemoglobin of 15.1 mg/dL D. A client who has dysphagia E. A client who experienced a drug overdose - CORRECT ANSWERS A, B, D, E A client who experienced a near-drowning incident has had trauma to the lungs and cerebral edema A client following coronary artery bypass graft surgery has had trauma to the chest A client who has dysphagia has difficulty swallowing and is at a risk for aspiration A client who experienced a drug overdose has damage to the central nervous system A nurse is reviewing discharge instructions for a client who experienced a pneumothorax. Which of the following should be included in the teaching? A. notify your provider if you experience weakness B. You should be able to return to work in 1 week C. You need to wear a mask when in crowded areas

UPDATED 2024/2025 WITH CORRECT VERIFIED

ANSWERS BEST GRADED A+ FOR PASS

D. Notify your provider if you experience a cough - CORRECT ANSWERS D. The client should notify the provider of a cough which may indicate that the client has a respiratory infection and should be treated A nurse is providing discharge teaching for a client who has a prescription for furosemide (Lasix) 40 mg PO daily. What time of day should the nurse encourage the client to take this medication? - CORRECT ANSWERS Morning The nurse evaluating a tuberculin test result 72 hours after it was administered notes an area of induration 9 m in diameter. What additional information indicates to the nurse that this is a positive result? A. The patient is an injection drug user B. The patient was born in Southeast Asia C. The patient has HIV D. The patient resides in a long-term care facility - CORRECT ANSWERS C. A 9-mm area of induration is a positive tuberculosis test result in a patient with HIV disease. Being an intravenous drug user, born in Southeast Asia, and residing in a long-term care facility are not criteria for a positive tuberculosis test with a 9-mm area of induration. A patient with arthritis has been taking over-the-counter NSAIDs for several years. Which questions should the nurse ask the patient while completing the health history? (Select all that apply) A. Do you know that you may become addicted to this drug? B. Tell me how and when you take this drug C. Have you ever vomited blood or had very dark stools? D. Do you have your blood pressure checked regularly? E. Have you noticed any problems with your breathing? - CORRECT ANSWERS B, C, D NSAIDs are more effective when taken on a scheduled basis for predictable pain rather than prn for occasional pain. These drugs can cause gastrointestinal bleeding and hypertension, necessitating regular follow-up. NSAIDs are not known to affect the respiratory tract and are not addictive.

UPDATED 2024/2025 WITH CORRECT VERIFIED

ANSWERS BEST GRADED A+ FOR PASS

The nurse is instructing a patient with asthma on the use of a metered-dose inhaler (MDI) for medication administration. What should the nurse teach the patient about the medications being provided through this device? A. Rinse the mouth after using the inhaler to reduce systemic absorption of the drug B. Use the anti-inflammatory drug as needed to treat acute episodes of wheezing C. Take quick shallow breaths in rapid succession while holding the canister down D. Use the inhaler containing the anti-inflammatory drug first, then the bronchodilator - CORRECT ANSWERS B. The anti-inflammatory effect of corticosteroids helps both prevent and treat acute episodes. Corticosteroids are used to reduce the frequency and severity of asthma attacks and allow reduced dosages of other drugs. These medications decrease the synthesis and release of inflammatory mediators, reduce inflammatory cell activation and infiltration, decrease airway edema, decrease mucous production in the airways, and increase the number and receptivity of beta2 receptors. Press and hold the canister down while inhaling deeply and slowly for 3 to 5 seconds. Then hold the breath for 10 seconds, release pressure on the container, remove from the mouth, and exhale. Wait 20 to 30 seconds before repeating the procedure for a second puff. Administer anti-inflammatory inhaler doses after bronchodilators to facilitate transit of the medication to distal airways. Rinse the mouth after using the inhaler to reduce the risk of fungal infections. A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse? A. I am allergic to morphine B. I take antacids several times a day C. I had a blood clot in my leg several years ago D. It hurts to take a deep breath - CORRECT ANSWERS B. The greatest risk to this client is the possibility of bleeding from a peptic ulcer. Further assessment should be completed and the nurse should notify the provider of the finding A nurse is caring for a client who is receiving hemodynamic monitoring readings: PAS 34 mm Hg, PAD 21 mm Hg, PAWP 16 mm Hg, CVP 12 mm Hg. For which of the following is the client at risk? (Select all that apply) A. Heart Failure B. Cor pulmonale

UPDATED 2024/2025 WITH CORRECT VERIFIED

ANSWERS BEST GRADED A+ FOR PASS

C. Hypovolemic shock D. Pulmonary hypertension E. Peripheral edema - CORRECT ANSWERS A, B, D, E A. Heart failure is associated with left ventricular failure and would be indicated by elevated hemodynamic readings B. Cor pulmonale is associated with the right side of the heart, and pulmonary problems would be indicated by elevated hemodynamic readings D. Pulmonary hypertension is associated with high blood pressure in the pulmonary arteries, affects the right side of the heart, and would be indicated by elevated hemodynamic readings E. Peripheral edema is associated with left ventricular failure and would be indicated by elevated hemodynamic readings A nurse is caring for a client who has global aphasia (both receptive and expressive). Which of the following should the nurse include in the client's plan of care? (select all that apply). A. Speak to the client at a slower rate B. Look directly at the client when speaking C. Allow extra time for the client to answer D. Complete sentences that the client cannot finish E. Give Instructions one step at a time - CORRECT ANSWERS A B C E A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure is in the client's room? (Select all that apply) A. oxygen equipment

UPDATED 2024/2025 WITH CORRECT VERIFIED

ANSWERS BEST GRADED A+ FOR PASS

B. Incentive spirometer C. Pulse oximeter D. Sterile dressing E. Suture removal kit - CORRECT ANSWERS A, C, D Oxygen equipment is necessary to have in the client's room if the client becomes short of breath following the procedure Pulse oximetry is necessary to monitor the client's oxygen saturation level during the procedure A sterile dressing is necessary to apply to the puncture site following the procedure A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse instruct the client to do? A. Lie on his left side B. Use the incentive spirometer C. Cough at regular intervals D. Perform the Valsalva maneuver - CORRECT ANSWERS D. The client should be instructed to take a deep breath, exhale, and bear down as the chest tube is being removed. This increases intrathoracic pressure and reduces the risk of an air embolism A nurse is caring for a client who has dyspnea and is to receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? A. Nonrebreather mask B. Venturi mask C. Nasal cannula D. Simple face mask - CORRECT ANSWERS B. A venturi mask incorporates an adapter that allows a precise amount of oxygen to be delivered to the client