ATI Med Surg Exam 6
Total Questions : 49
Showing 25 questions, Sign in for moreA nurse is caring for an older adult client who has a fractured hip and will require rehabilitative care. The client's family asks the nurse for information about this type of care. Which of the following explanations should the nurse provide?
Explanation
A. This option is correct. Rehabilitative care often involves educating the primary caregiver on how to assist the client in their recovery process.
B. This option suggests a focus on complete recovery, but rehabilitative care may also focus on adapting to new circumstances if complete recovery is not possible.
C. This option refers to the initiation of services, which may not specifically pertain to rehabilitative care.
D. This option incorrectly associates rehabilitative care exclusively with long-term care facilities. While rehabilitative care may occur in such facilities, it can also occur in other settings.
A nurse is caring for a client who has a prescription for balanced skeletal traction with a Thomas splint for the treatment of a fractured femur. Which of the following interventions should the nurse implement to prevent pressure points from developing around the edges of the splint?
Explanation
A. This option is correct. Removing the weights periodically helps relieve pressure on the skin and prevents pressure points from developing.
B. Applying lotion may not effectively prevent pressure points and could potentially lead to skin irritation.
C. Applying a foot plate to the bed is not directly related to preventing pressure points around the edges of the splint.
D. Repositioning the client is important for overall comfort and preventing complications but may not be sufficient to prevent pressure points from developing around the edges of the splint.
A nurse is caring for a client who is postoperative following an intermaxillary fixation as a result of multiple facial fractures. Which of the following types of equipment should the nurse plan to have at the client's bedside?
Explanation
A. An IV infusion pump may be needed for intravenous therapy but is not specific to postoperative care following intermaxillary fixation.
B. This option is correct. Wire cutters are essential equipment in case of an emergency that requires the removal of the fixation wires.
C. An NG tube may be necessary for nutritional support, but it is not directly related to postoperative care following intermaxillary fixation.
D. A urinary catheter tray is not specific to postoperative care following intermaxillary fixation and may not be a priority in this situation.
A nurse is teaching an older adult client who has osteoporosis about beginning a program of regular physical activity. Which of the following recommendations should the nurse make?
Explanation
A. Stretching exercises are beneficial for improving flexibility and range of motion, which can help prevent further complications in clients with osteoporosis.
B. High-impact aerobics can increase the risk of fractures in individuals with osteoporosis due to the stress on bones. It is not a recommended form of exercise.
C. Riding a bicycle is a low-impact exercise that can be beneficial for cardiovascular health, but it may not specifically address the needs of osteoporosis.
D. Walking briskly is a weight-bearing exercise that can help strengthen bones. It's a good recommendation for clients with osteoporosis, but stretching exercises are also important.
A nurse is caring for a client who has a new short-leg cast on his lower leg to treat an ankle fracture. Which of the following findings requires immediate notification of the provider?
Explanation
A. Ecchymosis of the distal foot may be expected after the application of a cast and is not necessarily an immediate concern unless it is severe or rapidly worsening.
B. Dependent edema distal to the cast can occur as a normal response to immobilization. It is not an immediate concern unless it is severe or associated with other concerning symptoms.
C. A moderate level of pain can be expected after the application of a cast. It should be managed appropriately, but it is not an immediate concern unless it is severe or uncontrolled.
D. Inability to flex the toes of the casted foot suggests a potential issue with circulation or nerve function, which requires immediate notification of the provider.
A nurse is assessing a client following the application of a leg cast for the treatment of a fracture. If the cast is too tight, which of the following findings should the nurse expect to observe first?
Explanation
A. Inability to move toes may be a sign of tightness in the cast, but it is not the first finding to be expected if the cast is too tight.
B. Pallor of the toes indicates compromised blood flow and is the earliest sign of circulatory impairment due to tightness of the cast.
C. Change in temperature of the toes may be a sign of impaired circulation, but it is not the earliest finding to be expected.
D. Edema of the toes may occur as a result of compromised circulation, but it is not the first finding to be expected if the cast is too tight.
A nurse is caring for a client who is postoperative hip arthroplasty and has a new prescription for enoxaparin 1 mg/kg/dose subcutaneously every 12 hr. The client weighs 95 lbs. How many mg should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
- To calculate the dose of enoxaparin, first convert the client's weight from pounds to kilograms by dividing by 2.2.
- 95 lbs / 2.2 = 43.18 kg
- Then, multiply the weight in kilograms by the prescribed dose of 1 mg/kg. - 43.18 kg x 1 mg/kg = 43.18 mg
- Finally, round the answer to the nearest tenth of a milligram.
- 43.18 mg ≈ 43.2 mg
- Therefore, the nurse should administer 43.2 mg of enoxaparin per dose subcutaneously every 12 hours.
A nurse is assessing a client who has carpal tunnel syndrome. The nurse should expect which of the following findings?
Explanation
A. Cool extremities are not typically associated with carpal tunnel syndrome. They may be a sign of poor circulation, but this is not a specific finding for carpal tunnel syndrome.
B. Decreased radial pulse is not a characteristic finding of carpal tunnel syndrome. It may indicate issues with blood flow to the hand but is not specific to this condition.
C. Positive Chvostek's sign is associated with hypocalcemia and involves facial muscle twitching when the facial nerve is tapped. It is not related to carpal tunnel syndrome.
D. Positive Phalen's sign is a characteristic finding in carpal tunnel syndrome. It involves tingling or numbness in the median nerve distribution (usually thumb, index, middle, and part of the ring finger) when the wrist is flexed for 60 seconds.
A nurse is caring for a client who has fractures of the symphysis pubis and pelvis. The nurse should monitor the client for which of the following findings of a common complication of pelvic fractures?
Explanation
A. Hematuria: This is the correct answer. Hematuria, which is the presence of blood in the urine, can be a common complication of pelvic fractures. This occurs due to the potential injury to the bladder or other structures within the pelvis. Monitoring for hematuria is crucial in assessing potential internal injuries and ensuring appropriate management.
B. Impaired taste: Impaired taste is not typically associated with pelvic fractures. It is more likely related to conditions involving the sense of taste or other unrelated factors. It is not a common complication of pelvic fractures.
C. Diarrhea: Diarrhea is not a common complication of pelvic fractures. It is more likely to be caused by gastrointestinal issues, infections, dietary factors, or other medical conditions. It is not directly related to pelvic fractures or their complications.
D. Increased thirst: Increased thirst is not a common complication of pelvic fractures. It may be related to various factors such as dehydration, certain medical conditions like diabetes, or side effects of medications. It is not a direct consequence of pelvic fractures or their associated complications.
A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority?
Explanation
A. Increasing the client's protein intake is important for overall healing, but it is not the top priority in the acute phase of osteomyelitis. The immediate priority is to administer antibiotics to address the infection.
B. This is the correct answer. Administering antibiotics is the top priority in the treatment of acute osteomyelitis. Timely administration of appropriate antibiotics is crucial in eradicating the infection and preventing further complications.
C. Providing the client with antipyretic therapy (to reduce fever) is important, but it is secondary to administering antibiotics. The underlying infection must be addressed first and foremost.
D. Teaching relaxation breathing to reduce pain may be beneficial for the client's comfort, but it is not the priority intervention. Controlling the infection with antibiotics takes precedence.
A nurse is preparing to administer naproxen 500 mg PO BID for a client who has osteoarthritis. The amount available is naproxen 125 mg/5 mL oral suspension. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
- To calculate the dose of naproxen oral suspension, use the following formula: Dose (mL) = Desired dose (mg) / Available dose (mg/mL)
- In this case, the desired dose is 500 mg and the available dose is 125 mg/5 mL, which is equivalent to 25 mg/mL
- Plug in the values into the formula: Dose (mL) = 500 mg / 25 mg/mL - Simplify the expression: Dose (mL) = 20 mL
- Round the answer to the nearest whole number: Dose (mL) = 20 mL
- The nurse should administer 20 mL of naproxen oral suspension per dose
A nurse is caring for a client who has an acute ankle sprain. Which of the following actions should the nurse take? (Select all that apply.)
Explanation
A. Place a compression bandage on the ankle.
- This helps reduce swelling and provides support to the injured area.
B. Apply heat to the ankle
- This action is not recommended for acute sprains as it can increase swelling. Cold packs or ice should be used initially to reduce inflammation.
C. Encourage rest.
- Rest is important to allow the ankle to heal properly and prevent further injury.
D. Elevate the ankle.
- Elevating the ankle helps reduce swelling by allowing fluid to drain away from the injured area.
E. Perform passive range-of-motion exercises to the ankle.
- Gentle range-of-motion exercises can help prevent stiffness in the ankle joint. However, it's important to perform these exercises within the limits of comfort and not force any movements.
A nurse is preparing to administer indomethacin 75 mg PO bid. Available is indomethacin 25 mg/5mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
- To calculate the mL per dose, use the formula: mL = (mg x 5) / 25
- Plug in the given values: mL = (75 x 5) / 25
- Simplify the equation: mL = 15
- Round the answer to the nearest whole number: mL = 15
- The nurse should administer 15 mL of indomethacin per dose.
A nurse is caring for a client who has a cast in place for a fractured tibia. Which of the following nursing actions is the priority immediately after the provider has applied the cast?
Explanation
A. Performing range of motion: This should not be done immediately after applying the cast, as it may compromise the integrity of the cast. Range of motion exercises should be initiated once the cast has fully set and as directed by the healthcare provider.
B. Checking capillary refill distal to the cast: This is the priority after applying the cast. It assesses blood flow to the extremity below the cast. Impaired circulation could lead to serious complications, so it's crucial to monitor capillary refill promptly.
C. Teaching the client about cast care: While providing education about cast care is important, it is not the immediate priority. Ensuring proper circulation is more critical in the initial moments after applying the cast.
D. Managing pain: While pain management is important, it is not the immediate priority after applying the cast. Ensuring proper circulation and assessing for any signs of impairment take precedence. Pain management can be addressed once circulation is confirmed to be adequate.
A nurse is caring for a client who has a severe gangrenous infection of the right lower extremity. The nurse should plan preoperative teaching based on the possibility of which of the following amputation procedures?
Explanation
A. "Your pain will gradually become less severe." This statement is accurate and provides realistic expectations for the client. After an amputation, there will be initial post operative pain, but it should gradually decrease over time.
B. "The pain will disappear soon." This statement is not accurate. While the pain will eventually decrease, it may not completely disappear immediately after the procedure.
C. "It's likely that you will have only a tingling sensation." This statement is not accurate. While some clients may experience tingling sensations, it is not the only sensation they may feel, and this statement does not cover the full range of possible experiences.
D. "Phantom pain is mostly psychological." This statement is not accurate. Phantom pain is a real sensation that some individuals experience after an amputation. It is believed to be related to nerve endings that continue to send signals to the brain even though the limb is no longer present. It is not purely psychological.
A nurse is preparing a client who is postoperative following a below-the knee amputation for a leg prosthesis fitting. Which of the following actions should the nurse take?
Explanation
A. Remove the elastic bandage and re-wrap the stump once per day: This is not recommended. The elastic bandage provides support and helps reduce swelling. It should only be removed and re-wrapped as directed by the healthcare provider.
B. Secure the elastic bandage to the lowest joint: The bandage should be secure, but it should not be tied too tightly or secured directly over a joint. This could restrict blood flow and cause discomfort.
C. Wrap the stump with an elastic bandage in a figure-eight configuration: This is the correct action. A figure-eight configuration helps distribute pressure evenly, providing support and reducing the risk of edema and complications.
D. Perform passive range-of-motion exercises once daily: Range-of-motion exercises are important, but they should be performed within the parameters set by the healthcare provider. They should not be performed only once daily, and it's essential to avoid overexertion or straining the residual limb.
A nurse is completing discharge teaching with a client following arthroscopic knee surgery. Which of the following instructions should the nurse include in the teaching?
Explanation
A. Remain on bedrest for the first 24 hr.: This is not recommended after arthroscopic knee surgery. Early mobilization and ambulation are encouraged to prevent complications such as blood clots and promote healing.
B. Apply ice to the affected area: This is an important instruction. Applying ice can help reduce swelling and pain after surgery. It's typically recommended for the first 24-48 hours.
C. Begin active range of motion: While range of motion exercises are important, they should be initiated as directed by the healthcare provider, and they should be done gently to avoid straining the surgical site.
D. Keep the leg in a dependent position: This is not recommended. Elevating the leg can help reduce swelling and promote circulation. Keeping the leg in a dependent position could exacerbate swelling and discomfort.
A nurse is preparing to administer moxifloxacin 400 mg by intermittent IV bolus over 60 min. Available is moxifloxacin 400 mg in 250 mL dextrose 5% (DSW). The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
- To calculate the gtt/min, use the formula: gtt/min = (volume in mL x drop factor in gtt/mL) / time in min
- Substitute the given values: gtt/min = (250 mL x 15 gtt/mL) / 60 min - Simplify and round: gtt/min = 62.5 gtt/min ≈ 63 gtt/min
- The nurse should set the manual IV infusion to deliver 63 gtt/min
A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take? (Select all that apply.)
Explanation
A. Position weights against the foot of the bed: Incorrect. Weights in Buck's traction are typically hung freely over the end of the bed to provide the necessary countertraction. Placing them against the foot of the bed would not serve this purpose.
B. Examine the skin under the traction splint: Correct. It's important to regularly assess the skin underneath the traction splint to ensure there are no signs of pressure ulcers or skin breakdown.
C. Monitor peripheral pulses in the affected extremity: Correct. This is essential to ensure that blood flow to the extremity is not compromised by the traction.
D. Assess the temperature of the affected extremity: Correct. Monitoring the temperature helps in identifying any signs of impaired circulation.
E. Adjust the prescribed weights every shift: This is not something that should be done without specific orders from the healthcare provider. Adjusting the weights should be done based on the specific plan of care and provider's instructions.
A nurse in the emergency department is caring for a client who has a compression fracture of a spinal vertebra. During transport to the facility. the client was medicated with intravenous morphine. On arrival, the neurosurgeon determined urgent surgical intervention is indicated for the fracture. Staff members have been unable to reach the client's family. Which of the following actions should the nurse anticipate the neurosurgeon taking?
Explanation
A. Delaying the surgery until a member of the client's family is reached may not be in the best interest of the client if urgent surgical intervention is indicated.
B. While naloxone can reverse the effects of opioids like morphine, it is not the primary action the neurosurgeon would take in this situation. The priority is addressing the urgent surgical need.
C. Invoking implied consent is the most appropriate action in this situation. Implied consent is assumed in emergency situations where the client is unable to provide consent, and delay would significantly jeopardize the client's health.
D. Asking the client to sign the surgical consent form would not be feasible in this situation since the client is likely not in a condition to provide informed consent due to the administration of intravenous morphine and the urgency of the surgical intervention.
A nurse is teaching a client who is scheduled for dual-energy x-ray absorptiometry (DXA) to screen for osteoporosis. Which of the following instructions should the nurse include in the teaching?
Explanation
A. Fasting is not necessary for a dual-energy x-ray absorptiometry (DXA) scan, as it does not involve ingesting anything.
B. The client does not need to lie flat for an extended period following a DXA scan. They can resume normal activities immediately after the test.
C. It is important to remove jewelry and metal objects before a DXA scan, as they can interfere with the accuracy of the results.
D. Correct. It is recommended to empty the bladder before the test to ensure comfort and accuracy of the results, as a full bladder can potentially interfere with the scan.
A nurse is assessing a client who reports numbness and pain in his right palm, index finger, and middle finger. The client reports working with a keyboard most of the time while at work. The nurse suspects carpal tunnel syndrome. Which of the following tests should the nurse request that the client perform?
Explanation
A. Holding the wrist at a 90-degree flexion is known as Phalen's maneuver, which is a test for carpal tunnel syndrome. This position puts pressure on the median nerve, potentially reproducing the client's symptoms.
B. Flexing the right arm at the elbow is not a specific test for carpal tunnel syndrome.
C. Holding the right arm straight is not a specific test for carpal tunnel syndrome.
D. Extending the right arm upward is not a specific test for carpal tunnel syndrome.
A nurse is caring for a client who has a fractured tibia as a result of a fall. The client's x-ray shows that the bone is splintered into several pieces around the shaft. The nurse should identify that the client has which of the following types of fractures?
Explanation
A. Transverse fractures occur straight across the bone. In this case, the bone is splintered, which is not characteristic of a transverse fracture.
B. Oblique fractures have a diagonal break across the bone. This does not match the description provided in the scenario.
C. Impacted fractures occur when one end of the bone is forced into the adjacent bone. This does not align with the description of the fracture in the scenario.
D. Correct. A comminuted fracture involves the bone breaking into multiple fragments or pieces. This aligns with the description provided in the scenario where the bone is splintered into several pieces around the shaft.
A nurse at an urgent care center is caring for four clients who all have leg or foot injuries. Which of the following client reports should suggest to the nurse that the client has an ankle sprain?
Explanation
A. Was hit by another soccer player on the field - This suggests a possible collision injury, which may result in various types of leg or foot injuries, but it doesn't specifically point to an ankle sprain.
B. Twisted his foot while running bases during a baseball game - This mechanism of injury is consistent with an ankle sprain. Twisting the foot during a sudden movement can cause stretching or tearing of ligaments around the ankle.
C. Has ankle pain after running a 16 km (10 mile) race - This suggests an overuse or strain injury, which could include various types of leg injuries, but it doesn't specifically point to an ankle sprain.
D. Dropped a 4.5 kg (10 lb) weight on his lower leg at a health club - This suggests a potential crush or impact injury to the lower leg, which may result in various types of leg injuries, but it doesn't specifically point to an ankle sprain.
A nurse is caring for a client who reports low back pain and asks the nurse for specific exercise recommendations. Which of the following activities should the nurse suggest?
Explanation
A. Rowing - This activity can put strain on the lower back and may exacerbate low back pain.
B. Tennis - This sport involves a lot of twisting and sudden movements, which can potentially worsen low back pain.
C. Canoeing - While generally a low-impact activity, it still requires core stability which could potentially aggravate low back pain.
D. Swimming - Swimming is a highly recommended exercise for individuals with low back pain. It is a low-impact activity that helps strengthen the muscles in the back, as well as other parts of the body, without putting excessive strain on the spine. Additionally, the buoyancy of water provides support, reducing the impact on the joints.
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