ATI SP 250 Exam 3 Med Surg Exam
Total Questions : 49
Showing 25 questions, Sign in for moreA nurse is caring for a client who has HIV.
Vital Signs
Physical Examination
Diagnostic Results
Vital Signs
Temperature 38.1° C (100.6° F)
Heart rate 122/min
Respiratory rate 26/min
BP 136/85 mm Hg
Oxygen saturation 93% on room air
The client is at risk for developing __________
Explanation
Tuberculosis is a bacterial infection that affects the lungs and can be transmitted through respiratory droplets. People with HIV are more susceptible to tuberculosis because their immune system is weakened by the virus. Tuberculosis can cause fever, cough, weight loss, and night sweats. The client's vital signs indicate that they have a fever and a high heart rate and respiratory rate, which could be signs of tuberculosis.
A nurse is caring for a female client who has rheumatoid arthritis and a new prescription for methotrexate. The client tells the nurse she is planning a pregnancy. Which of the following instructions should the nurse give the client?
Explanation
Methotrexate is a medication that interferes with cell division and can cause birth defects or miscarriage if taken during pregnancy. The medication can also pass into breast milk and harm the baby. Therefore, the nurse should advisethe client to stop taking methotrexate at least 3 months before trying to conceive and to use effective contraception while on the medication.
A nurse is planning an educational program about basal cell carcinoma. Which of the following information should the nurse plan to include?
Explanation
This is because basal cell carcinoma originates from the basal layer of the epidermis, which does not have access to blood vessels or lymphatics that can facilitate spreading to other organs. Basal cell carcinoma usually grows slowly and locally, and can be treated with surgery or radiation.
A nurse on a medical-surgical unit is caring for a newly admitted client with a diagnosis of R/O tuberculosis.
Which of the following findings should the nurse report to the provider?
Nurses' Notes
Day 1:
0900:
Client admitted from emergency department with hemoptysis, dull chest pain, increasing fatigue, anorexia, nausea, chest tightness, and 3.2 kg (7 Ib) weight loss in 2 weeks. Heart rate regular, lung sounds with crackles in bilateral upper lobes. No edema. Airborne precautions initiated upon admission.
Day 2:
Client reports shortness of breath, nausea, and fatigue. Crackles auscultated bilaterally throughout lung fields. Productive cough, with thick, blood-streaked sputum. Bowel sounds active, no edema.
Explanation
This is because tuberculosis can affect the liver and cause hepatotoxicity, especially if the client is taking anti-tuberculosis medications. The nurse should monitor the client's liver function tests, such as AST and ALT levels, and observe for signs of liver damage, such as yellow sclera, dark urine, clay-colored stools, and abdominal pain.
A nurse is caring for a client who is taking aspirin for arthritis. The nurse should identify which of the following findings as an adverse effect of this medication?
Explanation
This is because aspirin can cause salicylate toxicity, which can manifest as tinnitus, hearing loss, vertigo, headache, confusion, and hyperventilation. The nurse should monitor the client's serum salicylate level and advise the client to report any signs of toxicity to the provider.
A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider?
Explanation
Difficulty swallowing is the priority finding to report to the provider. Rationale: This is because difficulty swallowing can indicate airway edema, which can compromise breathing and oxygenation. The nurse should monitor the client's respiratory status and administer oxygen as prescribed. The other findings are also important, but not as urgent as airway obstruction.
A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?
Explanation
CD4-T-cell count 180 cells/mm3 is the nurse's priority. Rationale: This is because a low CD4-T-cell count indicates a high risk of opportunistic infections and impaired immune function. The nurse should implement infection prevention measures and monitor the client for signs of infection. The other values are not as critical as the CD4-T-cell count.
A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?
Explanation
This is because pursed-lip breathing helps to prevent air trapping and promote gas exchange by creating positive pressure in the airways. The nurse should also teach the client to exhale slowly and completely through pursed lips. The other interventions are not appropriate for a client who has COPD.
A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client?
Explanation
This is because emphysema causes destruction of alveolar walls and loss of elastic recoil, which leads to air trapping and hyperinflation of the lungs. This results in a barrel-shaped chest and increased chest circumference.
A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?
Explanation
This is because SLE is an autoimmune disorder that causes inflammation and damage to various tissues and organs, including the skin. A facial rash, also known as a malar rash or butterfly rash, is one of the characteristic signs of SLE and affects about half of people with the condition.
A nurse is teaching a client about risk factors for skin cancer. Which of the following statements by the client indicates an understanding of the teaching?
Explanation
This is because sunscreen protects the skin from ultraviolet (UV) radiation, which is a major risk factor for skin cancer. UV radiation can damage DNA and cause mutations that lead to abnormal cell growth and division. Sunscreen should be applied every day, regardless of the season or weather, as UV rays can penetrate clouds and reflect off snow and water.
A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?
Explanation
This is because burns to the face, neck, and upper extremities can compromise the airway, circulation, and mobility of the client. The nurse should monitor for signs of respiratory distress, infection, and contractures in these areas.
A nurse is caring for a client who has a new diagnosis of systemic lupus erythematosus (SLE) and asks where this disease originates within the body. The nurse should tell the client that SLE originates in which of the following locations in the body?
Explanation
This is because SLE is an autoimmune disorder that causes inflammation and damage to various organs and tissues, such as the skin, joints, kidneys, heart, and blood vessels. Connective tissue is a type of tissue that supports and binds other tissues and organs in the body.
A nurse is planning a presentation about HIV for a church-based group. Which of the following information about HIV transmission should the nurse include?
Explanation
This is because HIV is a virus that infects certain cells of the immune system, such as CD4 cells or T cells. HIV can be found in blood, semen, vaginal fluid, breast milk, and other body fluids that contain blood. HIV can be transmitted through sexual contact, sharing needles or syringes, mother-to-child transmission during pregnancy or breastfeeding, or occupational exposure to blood or body fluids.
A nurse in an emergency department is caring for a client who has deep partial- and full thickness burns to his chest, abdomen, and upper arms. What is the nurse's priority intervention for this client during the resuscitation of phase of injury?
Explanation
This is because inhalation injury can cause airway edema, obstruction, and respiratory failure, which can be life-threatening. The nurse should monitor the client's respiratory status, administer oxygen, and prepare for intubation if needed.
A nurse is planning care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care?
Explanation
This is because immunosuppression increases the risk of infection, and health care workers can be potential sources of pathogens. The nurse should use standard precautions, avoid invasive procedures, and restrict visitors who are ill.
A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB?
Explanation
This is because sputum culture can identify the presence and type of mycobacteria that cause TB, while other tests can only indicate exposure or infection. Sputum culture results may take several weeks, so treatment should be initiated based on clinical suspicion and other tests.
A nurse is assessing a client who has pulmonary tuberculosis. Which of the following findings should the nurse expect?
Explanation
This is because pulmonary tuberculosis causes inflammation and damage to the lungs, which reduces oxygen exchange and leads to fatigue and weakness.
A nurse in an emergency room is caring a the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?
Explanation
This is because inhalation injuries can compromise the airway and cause respiratory distress or failure, which can be life-threatening. The nurse should assess for signs such as soot, burns, hoarseness, or stridor.
A nurse in a clinic is collecting a history from a client who reports that a member of his family just received a diagnosis of pulmonary tuberculosis. The nurse should expect that the provider will prescribe which of the following diagnostic tests first?
Explanation
This is because a NAAT can detect the presence of Mycobacterium tuberculosis DNA in a sputum sample within hours, which can confirm the diagnosis and guide treatment decisions. A sputum culture for AFB can take several weeks to yield results, while a chest x-ray or a CT scan can only show suggestive findings but not confirm the diagnosis.
A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?
Explanation
This is because central cyanosis reflects a decrease in arterial oxygen saturation and is best seen in areas where blood vessels are close to the surface, such as the oral mucosa, tongue, and lips. Peripheral cyanosis, which may be caused by vasoconstriction or poor circulation, can be seen in the soles of the feet, ear lobes, and nail beds, but it does not necessarily indicate hypoxemia.
A nurse is admitting a client who is having an exacerbation of his asthma. When reviewing the provider's orders, the nurse recognizes that clarification is needed for which of the following medications?
Explanation
The nurse should clarify with the provider why this medication is ordered and if there are any alternatives that are safer for the client. The other medications are appropriate for a client who has asthma.
A nurse is providing dietary teaching for a client who has chronic obstructive pulmonary disease. Which of the following instructions should the nurse include?
Explanation
The nurse should also advise the client to drink fluids between meals, eat small frequent meals, and increase protein intake to maintain muscle mass and immune function.
A nurse in a provider's office is assessing a client who has AIDS. The nurse notes that the client has multiple and widespread raised, purplish- brown skin lesions. The nurse should recognize that these findings indicate which of the following conditions?
Explanation
The lesions are caused by human herpesvirus 8 and can appear anywhere on the body, but are more common on the face, trunk, and extremities. The other conditions are not associated with AIDS or immunosuppression.
A nurse is teaching a client who has tuberculosis and is to start medication therapy with isoniazid, rifampin and pyrazinamide. Which of the following instructions should the nurse include?
Explanation
Pyrazinamide is a medication used to treat tuberculosis that can cause renal damage and crystal formation in the urine if not adequately hydrated. The client should also avoid alcohol and have regular liver function tests while taking this medication. Isoniazid should not be taken with antacids, as they can decrease its absorption and effectiveness. Sputum cultures are expected to be negative after 2 months of therapy, not 6 months. Providing a sputum specimen every 2 weeks is not an instruction for the client, but a part of the monitoring process by the health care team.
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