SP 250 Exam 3 Med Surg Exam
ATI SP 250 Exam 3 Med Surg Exam
Total Questions : 49
Showing 10 questions Sign up for moreA nurse is caring for a client who has HIV.
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.
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