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Ati Adult medical surgical assessment 2
Ati Adult medical surgical assessment 2
Total Questions : 43
Showing 10 questions Sign up for moreA nurse is caring for a client who has active tuberculosis. Which of the following actions should the nurse take?
Explanation
Choice A Reason:
Remaining 1 meter (3 feet) away from the client when providing care is not sufficient to prevent the spread of tuberculosis (TB). TB is an airborne disease, and the bacteria can remain suspended in the air for several hours. Therefore, maintaining a distance alone does not provide adequate protection against inhaling the bacteria.
Choice B Reason:
Applying a surgical mask before entering the client’s room is not the most effective measure. Surgical masks are designed to protect against large droplets and splashes, but they do not provide adequate protection against airborne particles like TB bacteria. Instead, healthcare workers should use N95 respirators, which are specifically designed to filter out airborne particles.
Choice C Reason:
Ensuring the door to the client’s room is closed at all times is a critical measure in preventing the spread of TB. This action helps to contain the airborne bacteria within the room, reducing the risk of transmission to others in the healthcare facility. This is part of airborne precautions, which are essential for managing patients with active TB.
Choice D Reason:
Placing a “no visitors” sign on the client’s door can help limit the number of people exposed to the TB bacteria, but it is not the most critical action. While it is important to restrict visitors, ensuring the door is closed and using appropriate personal protective equipment (PPE) are more effective measures in controlling the spread of TB.
A nurse is providing teaching to a client who has a new onset of genital herpes. Which of the following statements should the nurse include in the teaching?
Explanation
Choice A Reason
“You are not contagious when lesions are healed.” This statement is incorrect. Genital herpes can still be contagious even when there are no visible lesions. The virus can be shed from the skin and transmitted to others even in the absence of symptoms.
Choice B Reason
“This infection is spread through the air.” This statement is incorrect. Genital herpes is not spread through the air. It is primarily transmitted through direct skin-to-skin contact, particularly during sexual activity.
Choice C Reason
“Stress can activate an outbreak.” This statement is correct. Stress is a known trigger for reactivation of the herpes simplex virus, leading to outbreaks of genital herpes. Other triggers can include illness, fatigue, and immune suppression.
Choice D Reason
“Antiviral drugs will cure the infection.” This statement is incorrect. While antiviral drugs can help manage symptoms and reduce the frequency of outbreaks, they do not cure the infection. The herpes simplex virus remains in the body and can reactivate.
A nurse is reviewing laboratory reports for a client who is taking NSAIDs for rheumatoid arthritis. Which of the following results should the nurse recognize as a possible adverse effect of NSAID therapy?
Explanation
Choice A Reason
Increased erythrocyte sedimentation rate (ESR) is a marker of inflammation and is commonly elevated in conditions like rheumatoid arthritis. However, it is not a direct adverse effect of NSAID therapy. NSAIDs are more likely to cause gastrointestinal issues, such as bleeding, which would be detected by a fecal occult blood test.
Choice B Reason
Elevated creatinine clearance is not typically associated with NSAID use. In fact, NSAIDs can potentially reduce kidney function, leading to decreased creatinine clearance. Therefore, this option is incorrect.
Choice C Reason
Increased serum potassium levels can occur with NSAID use, especially in patients with compromised kidney function. However, this is less common compared to gastrointestinal bleeding, which is a more direct and frequent adverse effect of NSAID therapy.
Choice D Reason
Positive fecal occult blood test is the correct answer. NSAIDs can cause gastrointestinal bleeding, which can be detected through a fecal occult blood test. This is a well-documented adverse effect of NSAID therapy and is a significant concern for patients on long-term NSAID treatment.
A nurse is providing discharge teaching to a client who has acute leukemia and received chemotherapy 12 hours ago. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
Explanation
Choice A Reason:
Using an electric shaver is recommended for clients who have received chemotherapy because it reduces the risk of cuts and bleeding. Chemotherapy can lower platelet counts, leading to an increased risk of bleeding. Traditional razors can cause nicks and cuts, which can be problematic for clients with low platelet counts.
Choice B Reason:
Avoiding crowds is crucial for clients who have received chemotherapy because their immune systems are often weakened, making them more susceptible to infections. Crowded places increase the risk of exposure to pathogens, which can lead to serious infections in immunocompromised individuals.
Choice C Reason:
Taking temperature weekly is not sufficient for clients who have received chemotherapy. These clients are at a higher risk of infections, and any sign of fever should be monitored closely. It is generally recommended to take the temperature daily or more frequently if the client feels unwell.
Choice D Reason:
Consuming a low-residue diet is not typically necessary for clients who have received chemotherapy unless they are experiencing specific gastrointestinal issues. A balanced diet with adequate nutrients is usually recommended to support overall health and recovery.
Choice E Reason:
Monitoring for bruising is important for clients who have received chemotherapy because it can indicate low platelet counts or other bleeding disorders. Early detection of bruising can help in managing and preventing more serious bleeding complications.
A nurse is planning care for a client who has acute pancreatitis. Which of the following interventions should the nurse include in the client’s plan? (Select all that apply.)
Explanation
Choice A Reason:
Initiating an insulin drip is not a standard intervention for all clients with acute pancreatitis. This intervention is typically reserved for clients who develop hyperglycemia or diabetes as a complication of pancreatitis. Acute pancreatitis can affect the pancreas’ ability to produce insulin, but not all clients will require an insulin drip.
Choice B Reason:
Monitoring blood glucose levels is crucial for clients with acute pancreatitis because the pancreas plays a key role in regulating blood sugar. Inflammation or damage to the pancreas can lead to fluctuations in blood glucose levels, making regular monitoring essential to manage potential hyperglycemia or hypoglycemia.
Choice C Reason:
Continuing a regular diet as tolerated is not appropriate for clients with acute pancreatitis. These clients are typically kept NPO (nothing by mouth) to rest the pancreas and reduce the secretion of pancreatic enzymes, which can exacerbate inflammation and pain.
Choice D Reason:
Maintaining NPO status until the client is pain-free is a standard intervention for acute pancreatitis. This approach helps to rest the pancreas and prevent the release of digestive enzymes that can further inflame the pancreas. Once the client is pain-free and inflammation has subsided, a gradual reintroduction of oral intake can be considered.
Choice E Reason:
Managing acute pain is a critical aspect of care for clients with acute pancreatitis. Pain management can include medications such as opioids, as well as non-pharmacological interventions like positioning and relaxation techniques. Effective pain management improves the client’s comfort and can help reduce stress on the pancreas.
A nurse is caring for a client who has burn injuries covering their upper body and is concerned about their altered appearance. Which of the following statements should the nurse make?
Explanation
Choice A Reason
“It is okay to not want to touch the burned areas of your body.” This statement is empathetic and acknowledges the client’s feelings, but it does not provide a constructive way to address their concerns about altered appearance. While it is important to validate the client’s feelings, offering a solution or support mechanism is more beneficial.
Choice B Reason
“Cosmetic surgery should be performed within the next year to be effective.” This statement is misleading. While timely intervention can be important, the timing of reconstructive or cosmetic surgery depends on various factors, including the extent of the burns, the healing process, and the patient’s overall health. It is not accurate to generalize that surgery must be performed within a year.
Choice C Reason
“Reconstructive surgery can completely restore your previous appearance.” This statement is incorrect and can give false hope. Reconstructive surgery aims to improve function and appearance, but it cannot completely restore the previous appearance. Managing expectations is crucial in the recovery process.
Choice D Reason
“It could be helpful for you to attend a support group for people who have burn injuries.” This statement is correct. Support groups provide emotional and psychological support, helping burn survivors cope with changes in appearance and other challenges. They offer a sense of community and shared experiences, which can be very beneficial for recovery.
A nurse is planning care for a client who has acute pancreatitis. Which of the following interventions should the nurse include in the client’s plan? (Select all that apply.)
Explanation
Choice A Reason
Initiate insulin drip. This intervention is not typically included in the standard care plan for all patients with acute pancreatitis. Insulin drips are generally reserved for cases of hypertriglyceridemia-induced pancreatitis, where insulin helps to lower triglyceride levels. For most patients with acute pancreatitis, this is not a standard intervention.
Choice B Reason
Monitor blood glucose levels. This is a correct intervention. Acute pancreatitis can affect the pancreas’ ability to regulate blood sugar, leading to hyperglycemia or hypoglycemia. Monitoring blood glucose levels helps in managing these potential complications and ensuring appropriate treatment.
Choice C Reason
Continue regular diet as tolerated. This statement is incorrect. Patients with acute pancreatitis are usually kept NPO (nothing by mouth) initially to rest the pancreas. Once the inflammation subsides, they may gradually reintroduce oral intake starting with clear liquids and progressing to a low-fat diet.
Choice D Reason
Maintain NPO status until pain-free. This is partially correct but not entirely accurate. While initial management often includes NPO status to rest the pancreas, current guidelines suggest that early enteral feeding can be beneficial and should be started as soon as tolerated. Prolonged NPO status is no longer the standard of care.
Choice E Reason
Manage acute pain. This is a correct intervention. Pain management is a critical component of care for patients with acute pancreatitis. Effective pain control improves patient comfort and can help reduce the stress response associated with severe pain.
A nurse is caring for a client who has a peripherally inserted central catheter (PICC). For which of the following findings should the nurse notify the provider?
Explanation
Choice A Reason:
The dressing for a PICC line should be changed every 7 days or sooner if it becomes wet, soiled, or loose. Therefore, a dressing change 7 days ago is within the recommended guidelines and does not necessarily require immediate notification of the provider.
Choice B Reason:
An increase in the circumference of the client’s upper arm by 10% can indicate swelling, which may be a sign of complications such as infection, thrombosis, or infiltration. This finding should be promptly reported to the provider for further evaluation and intervention.
Choice C Reason:
The catheter not being used for 8 hours is not typically a cause for concern as long as it is properly flushed and maintained. PICC lines can remain in place for extended periods without use, provided they are flushed regularly to prevent occlusion.
Choice D Reason:
Flushing the catheter with 10 mL of sterile saline after medication use is a standard practice to maintain patency and prevent blockage This action does not require notification of the provider unless there are other associated complications.
A nurse is preparing to discharge a client who has a new diagnosis of chronic kidney disease (CKD). Which of the following referrals should the nurse plan to initiate?
Explanation
Choice A Reason:
Respiratory therapy is not typically required for clients with chronic kidney disease unless they have concurrent respiratory issues. CKD primarily affects the kidneys and related systems, so respiratory therapy is not a standard referral for these patients.
Choice B Reason:
Hospice care is generally reserved for clients with terminal illnesses who are nearing the end of life. While CKD can be a serious condition, many clients manage it with appropriate treatment and lifestyle changes. Therefore, hospice care is not a standard referral for newly diagnosed CKD patients.
Choice C Reason:
Occupational therapy may be beneficial for clients with CKD who experience difficulties with daily activities due to fatigue or other symptoms. However, it is not the most immediate or essential referral upon initial diagnosis.
Choice D Reason:
Dietary services are crucial for clients with chronic kidney disease. Proper nutrition can help manage symptoms, slow disease progression, and improve overall health. A dietitian can provide personalized dietary plans to ensure the client avoids foods that may exacerbate their condition and includes those that support kidney health.
A nurse is monitoring a client who has a traumatic brain injury and a ventriculostomy drain. The nurse should report which of the following findings as a complication of this therapeutic procedure? (Select all that apply.)
Explanation
Choice A Reason:
Infection is a significant complication of a ventriculostomy drain. The presence of a foreign object in the brain increases the risk of infections such as meningitis or ventriculitis. Signs of infection can include fever, redness, swelling at the insertion site, and changes in mental status.
Choice B Reason:
Vomiting can be a sign of increased intracranial pressure (ICP), which is a serious complication in clients with a traumatic brain injury and a ventriculostomy drain. Increased ICP can lead to further brain injury and requires immediate medical attention.
Choice C Reason:
Widening pulse pressure (the difference between systolic and diastolic blood pressure) can indicate increased intracranial pressure. This is a critical finding that should be reported immediately as it can signify worsening brain injury or other complications.
Choice D Reason:
Equal and reactive pupils are generally a normal finding and do not indicate a complication. This suggests that the brainstem is functioning properly and there is no significant increase in intracranial pressure affecting the cranial nerves.
Choice E Reason:
An intracranial pressure reading of 10 mm Hg is within the normal range (typically 7-15 mm Hg for adults). Therefore, this finding does not indicate a complication and does not require immediate reporting.
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