ATI RN Med Surg Custom Exam 2
Total Questions : 50
Showing 25 questions, Sign in for moreA nurse is preparing to administer 10 units of regular insulin and 20 units of NPH insulin to a client who has diabetes mellitus.
When mixing the two types of insulin, which of the following actions should the nurse take first?
Explanation
Choice A rationale:
Replacing the needle for withdrawal with a safety needle is not the first step in mixing insulin. It is important to maintain sterility and prevent needle stick injuries, but this is not the first step.
Choice B rationale:
Injecting 20 units of air into the NPH insulin vial is not the first step in mixing insulin. This step is performed after injecting air into the regular insulin vial.
Choice C rationale:
Injecting 10 units of air into the regular insulin vial is the first step in mixing insulin. This prevents a vacuum from forming in the vial and allows for easier withdrawal of the insulin.
Choice D rationale:
Withdrawing 10 units of insulin from the regular insulin vial is not the first step in mixing insulin. This step is performed after injecting air into both vials.
A nurse is caring for a client and identifies an infiltration at the IV catheter site. Identify the order the nurse should perform the following actions.
(Move the steps into the box on the right, placing them in the selected order of performance. All steps must be used.).
Explanation
Choice A rationale:
Removing the IV catheter is not the first step when managing an infiltration. It is done after stopping the infusion to prevent further infiltration.
Choice B rationale:
Applying warm or cold compresses is not the first step when managing an infiltration. It is done after removing the IV catheter and applying a sterile dressing to reduce swelling and discomfort.
Choice C rationale:
Stopping the infusion is the first step when managing an infiltration. This prevents further infiltration of the IV fluid into the surrounding tissues.
Choice D rationale:
Applying a sterile dressing is not the first step when managing an infiltration. It is done after removing the IV catheter to protect the site from infection.
Choice E rationale:
Elevating the extremity is not the first step when managing an infiltration. It is done after applying warm or cold compresses to reduce swelling.
While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard.
Which of the following actions should the nurse take first?
Explanation
Choice A rationale:
Determining if the client needs to continue IV therapy is important, but it is not the first action the nurse should take. The nurse should first address the immediate problem, which is the irritated IV site.
Choice B rationale:
Initiating a new IV line in the other extremity is necessary, but not the first action. The nurse should first discontinue the existing IV line to prevent further irritation or infection.
Choice C rationale:
The nurse should first discontinue the existing IV line. This is because the symptoms indicate that the client might have developed phlebitis, an inflammation of the vein, which requires immediate discontinuation of the IV line.
Choice D rationale:
Applying a hot pack to the irritated site can help reduce inflammation and discomfort, but it is not the first action. The nurse should first discontinue the IV line to prevent further complications.
A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease.
Which of the following sets of values should the nurse expect?.
Explanation
Choice A rationale:
These values indicate metabolic acidosis, which is common in clients with chronic kidney disease. The kidneys are unable to excrete hydrogen ions and reabsorb bicarbonate, leading to a low pH and low bicarbonate levels.
Choice B rationale:
These values indicate alkalosis, not typically associated with chronic kidney disease. The pH is high, indicating a basic or alkaline state, and the bicarbonate level is normal.
Choice C rationale:
These values indicate metabolic alkalosis, which is not typically seen in clients with chronic kidney disease. The pH and bicarbonate levels are both high.
Choice D rationale:
These values indicate respiratory acidosis, not typically associated with chronic kidney disease. The high PaCO2 level indicates that the lungs are not effectively eliminating CO2, leading to acidosis.
A nurse is teaching about risk factors for developing a stroke with a group of older adult clients.
Which of the following nonmodifiable risk factors should the nurse include?.
Explanation
Choice A rationale:
While hypertension is a risk factor for stroke, it is modifiable through lifestyle changes and medication.
Choice B rationale:
Smoking is a modifiable risk factor for stroke. Quitting smoking can significantly reduce the risk of stroke.
Choice C rationale:
Obesity is a modifiable risk factor for stroke. Weight loss and maintaining a healthy weight can reduce the risk of stroke.
Choice D rationale:
Genetics is a nonmodifiable risk factor for stroke. Individuals with a family history of stroke are at a higher risk, and this cannot be changed.
While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness.
Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care?
Explanation
Choice A rationale:
Varicose veins with ulcerations and lower extremity edema indicate poor blood flow, hence impaired tissue perfusion is the priority.
Choice B rationale:
While activity tolerance might be affected, it’s not the immediate concern.
Choice C rationale:
Impaired skin integrity is a concern due to ulcerations, but it’s secondary to impaired perfusion.
Choice D rationale:
Body image might be affected, but it’s not a physiological priority.
A nurse is caring for a client who will have blood sampling for a serum creatinine level and asks what this test shows.
Which of the following responses should the nurse make?
Explanation
Choice A rationale:
Serum creatinine level is a reliable indicator of kidney function.
Choice B rationale:
While it can indicate severe renal impairment, it doesn’t diagnose specific diseases.
Choice C rationale:
It doesn’t specifically test for medication interference.
Choice D rationale:
It’s the nurse’s role to provide this information, not defer to the doctor.
A nurse is preparing to administer gabapentin 900 mg PO once daily for a client who has neuropathic pain.
The amount available is gabapentin 300 mg/capsule.
How many capsules 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
The correct answer is3 capsules. Calculation: 900 mg (desired dose) / 300 mg (available dose) = 3 capsules.
A nurse in a clinic is interviewing a client who has a possible diagnosis of endometriosis.
Which of the following findings in the client's history should the nurse recognize as consistent with a diagnosis of endometriosis?
Explanation
Choice A rationale:
Abdominal bloating can occur in many conditions and is not specific to endometriosis.
Choice B rationale:
An atypical Papanicolaou smear is not related to endometriosis, it’s more associated with cervical abnormalities.
Choice C rationale:
A history of pelvic inflammatory disease (PID) is not a specific indicator of endometriosis.
Choice D rationale:
Dysmenorrhea (painful menstrual periods) that is unresponsive to NSAIDs is a common symptom of endometriosis.
A nurse is assessing a client who is receiving total parenteral nutrition (TPN) therapy via an infusion pump.
Which of the following actions should the nurse take?
Explanation
Choice A rationale:
The IV site dressing should be changed every 7 days, not every 4 days.
Choice B rationale:
The client’s blood glucose should be monitored every 4-6 hours, not every 12 hours.
Choice C rationale:
The client should be weighed daily, not every other day.
Choice D rationale:
The IV tubing for TPN should be changed every 24 hours to prevent infection.
A nurse is assessing a client who has diabetes insipidus.
Which of the following findings should the nurse expect?
Explanation
Choice A rationale:
Bradycardia is not a typical symptom of diabetes insipidus.
Choice B rationale:
Dehydration is a common symptom of diabetes insipidus due to excessive urination.
Choice C rationale:
Hyperglycemia is not a symptom of diabetes insipidus, but rather diabetes mellitus.
Choice D rationale:
Polyphagia (excessive hunger) is not a symptom of diabetes insipidus.
A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities.
Which of the following interventions should the nurse perform first?
Explanation
Choice A rationale:
Administering pain medication is important, but it’s not the first priority. The first priority is to stabilize the client’s condition.
Choice B rationale:
Administering a tetanus booster is necessary for burn patients, but it’s not the first intervention. The first intervention should be to stabilize the client’s condition.
Choice C rationale:
Cleaning and dressing the wound is important, but it’s not the first intervention. The first intervention should be to stabilize the client’s condition.
Choice D rationale:
Administering IV fluids is the first intervention for a burn patient. This is because burns can cause significant fluid loss, leading to dehydration and shock.
A nurse is caring for a client who has benign prostatic hyperplasia (BPH). Which of the following medications should the nurse plan to administer?
Explanation
Choice A rationale:
Fluoxymesterone is a synthetic anabolic steroid but it’s not used for BPH.
Choice B rationale:
Danazol is a synthetic steroid that is used to treat endometriosis, but it’s not used for BPH.
Choice C rationale:
Methyltestosterone is a synthetic anabolic steroid but it’s not used for BPH.
Choice D rationale:
Finasteride is a medication that is used to treat BPH. It works by decreasing the size of the prostate gland.
A nurse is assessing a client who is brought to the emergency room with burn injuries.
Which of the following findings should the nurse identify as a deep partial-thickness burn?
Explanation
Choice A rationale:
A pink color with blisters present is indicative of a superficial partial-thickness burn, not a deep partial-thickness burn.
Choice B rationale:
A yellow color with severe edema is indicative of a deep partial-thickness burn. This type of burn involves the entire dermis and damage to nerve endings, blood vessels, and sweat glands.
Choice C rationale:
A black color and absence of pain is indicative of a full-thickness burn, not a deep partial-thickness burn.
Choice D rationale:
A red color with eschar present is indicative of a full-thickness burn, not a deep partial-thickness burn.
A nurse is teaching a client who has fibrocystic breast condition (FBC) about strategies to minimize discomfort.
Which of the following instructions should the nurse include in the teaching?
Explanation
Choice A rationale:
Limiting dietary intake of salt prior to menses can help reduce fluid retention and breast swelling, thus minimizing discomfort.
Choice B rationale:
Taking tub baths doesn’t necessarily minimize discomfort associated with FBC. Hot water running over the breast tissue doesn’t have a significant impact on FBC symptoms.
Choice C rationale:
Removing the bra at night might provide some relief but it’s not a primary strategy for minimizing discomfort in FBC.
Choice D rationale:
Reducing fluid intake to 1 liter per day during menstruation is not recommended. Adequate hydration is important for overall health.
A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke.
Which of the following instructions should the nurse include?
Explanation
Choice A rationale:
Encouraging brief exercise before meals to promote appetite is not directly related to feeding safety for a client who has dysphagia following a stroke.
Choice B rationale:
Placing the client with the head reclined back to facilitate swallowing is incorrect. It’s safer for the client to sit upright during feeding to prevent aspiration.
Choice C rationale:
Encouraging the client to take small bites can help prevent choking and aspiration, making it a safe feeding practice for clients with dysphagia.
Choice D rationale:
Placing food in the affected side of the mouth is not a safe practice. It’s recommended to place food on the unaffected side of the mouth.
A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts.
The nurse should expect the client to report:
Explanation
Choice A rationale:
Having a loss of peripheral vision is not a typical symptom of cataracts. This symptom is more associated with conditions like glaucoma.
Choice B rationale:
Loss of central vision is not a typical symptom of cataracts. This symptom is more associated with conditions like macular degeneration.
Choice C rationale:
Having a decreased ability to perceive colors is a common symptom of cataracts. Cataracts can cause vision to become cloudy or yellowed, affecting color perception.
Choice D rationale:
Seeing bright flashes of light and floaters are not typical symptoms of cataracts. These symptoms are more commonly associated with conditions like retinal detachment.
A nurse is teaching about disease management for a client who has type 1 diabetes mellitus.
Which statement made by the client indicates an understanding of the teaching?
Explanation
Choice A rationale:
Weight reduction programs are generally beneficial for type 2 diabetes, not type 1.
Choice B rationale:
Insulin does not permit unrestricted dietary choices.
Choice C rationale:
Insulin injections are often given in the abdominal area due to its high vascularity, promoting faster absorption.
Choice D rationale:
Blood sugar readings are typically taken before meals to determine insulin dosage.
A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication?
Explanation
Choice A rationale:
While aspirin does have anti-inflammatory properties, this is not the primary reason it is prescribed post-MI.
Choice B rationale:
Aspirin does have antipyretic properties, but this is not relevant to a history of MI.
Choice C rationale:
Aspirin can act as an analgesic, but this is not the main reason for its prescription post-MI.
Choice D rationale:
Aspirin is an antiplatelet aggregate that helps prevent further clot formation, a key factor in MI treatment.
A nurse is teaching an older adult client who has diabetes mellitus about preventing the long-term complications of retinopathy and nephropathy.
Which of the following instructions should the nurse include?
Explanation
Choice A rationale:
Examining feet daily is important for preventing complications related to peripheral neuropathy, not retinopathy or nephropathy.
Choice B rationale:
Maintaining stable blood glucose levels can help prevent microvascular complications such as retinopathy and nephropathy.
Choice C rationale:
Annual eye examinations are important, but they do not prevent retinopathy.
Choice D rationale:
Wearing compression stockings daily is not directly related to preventing retinopathy or nephropathy.
A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site.
Which of the following actions should the nurse take first?
Explanation
Choice A rationale:
Applying a cold pack to the client’s upper arm would not be the first action to take. It may help reduce swelling, but it does not address the underlying issue.
Choice B rationale:
Measuring the circumference of both upper arms is the correct first action. This will provide objective data about the extent of the swelling, which can then be reported to the healthcare provider.
Choice C rationale:
Removing the PICC line is not the first action to take. This should only be done under the direction of a healthcare provider.
Choice D rationale:
Notifying the provider who inserted the PICC line is important, but it should be done after gathering all necessary data, including measuring the arm circumference.
A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.)
Explanation
Choice A rationale:
Localized edema is a common sign of infection. The body sends extra fluid to the area as part of the inflammatory response.
Choice B rationale:
An increase in neutrophils, a type of white blood cell, is a common response to infection. Neutrophils are part of the body’s immune response and work to fight off invading bacteria.
Choice C rationale:
An increase in platelets is not typically associated with infection. Platelets are involved in blood clotting, not the immune response.
Choice D rationale:
Bradycardia, or a slow heart rate, is not typically associated with infection. Infection usually causes an increased heart rate, not a decreased one.
Choice E rationale:
An increase in RBCs is not typically associated with infection. RBCs carry oxygen around the body, but their number does not usually change in response to infection.
A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8° C (98.2° F).
Which of the following actions should the nurse perform?
Explanation
Choice A rationale:
Completing a neurological check is the correct action. The client’s sudden confusion and drowsiness could indicate a neurological issue, such as a stroke.
Choice B rationale:
Increasing the client’s fluid intake is not the first action to take. While dehydration can cause confusion, other causes need to be ruled out first.
Choice C rationale:
Administering the prescribed PRN antihypertensive medication is not the first action to take. The client’s blood pressure is not elevated, so this medication is not needed at this time.
Choice D rationale:
Holding the client’s evening dose of digoxin is not the first action to take. The client’s symptoms are not necessarily related to this medication.
A nurse is caring for a client who reports an area of redness, warmth, tenderness, and pain in the right calf.
The nurse anticipates which of the following orders when notifying the provider of this finding?
Explanation
Choice A rationale:
Impedance plethysmography is a test that uses electrical signals to measure blood flow and can be used to detect deep vein thrombosis (DVT). However, it is not the first-line diagnostic tool for DVT.
Choice B rationale:
Cold therapy can help reduce inflammation and pain, but it is not a diagnostic measure for DVT.
Choice C rationale:
Venous duplex ultrasound is the most common test used to diagnose DVT. It uses sound waves to create pictures of the blood flowing through the veins in the leg.
Choice D rationale:
Homan’s sign is a physical examination finding that was traditionally used to diagnose DVT, but it is not reliable or specific.
A nurse is assessing a client who has fluid overload.
Which of the following findings should the nurse expect? (Select all that apply.).
Explanation
Choice A rationale:
Increased heart rate is a compensatory mechanism to maintain cardiac output in the presence of fluid overload.
Choice B rationale:
Increased respiratory rate may occur due to pulmonary congestion caused by fluid overload.
Choice C rationale:
Increased temperature is not typically associated with fluid overload.
Choice D rationale:
Increased hematocrit would indicate dehydration, not fluid overload.
Choice E rationale:
Increased blood pressure can occur due to increased blood volume in fluid overload.
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