a. Herpes Zostere. Pneumococcal Polysaccharide54. MISSING72. Missingb. Administer 0.9% sodium chlorideB, C, A, D, ERemain with the client for the first 15 to 30 minutes of the infusionc. “I’m going to include more cantaloupe in my diet.” (p. 4115)MED SURG →PRIORITYTWO1. A nurse is assessing a client who is 12hr postoperative following a colon resection. Which of the following findings should the nurse report to the surgeon?a. Heart rate 90/minb. Absent bowel soundsc. Hgb 8.2 g/dld. Gastric pH of 3.0Rationale: Normal Hgb is 13-18M g/dl, 12-16 g/dl. This may indicate a possible hemorrhaging.2. A nurse is caring for a client who has diabetes insipidus. Which of the following medications should the nurse plan toadminister?a. Desmopressinb. Regular insulinc. Furosemided. Lithium carbonateRationale: Diabetes Insipidus has decreased ADH. Administer Desmopressin/Vasopressin increase ADH and to stop patient on urinating.3. A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily for 3 years.Which of the following test should the nurse monitor?a. Fasting blood glucoseb. Stool for occult blood - GI bleedc. Urine for white blood cellsd. Serum calciumRationale: ATI Pharm 16. Pg. 485 Ibuprofen (NSAIDs) monitor for GI bleed (bloody,tarry stools, abdominal pain).4. A nurse in the emergency department is assessing a client. Which of the following actions should the nurse takefirst (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories ofdata.)a. Obtain a sputum sample for cultureb. Prepare the client for a chest x-rayc. Initiate airborne precautionsd. Administer ondansetron.Rationale: No idea what the Exhibit is all about; won’t be able to answer it.5. A nurse is contacting the provider for a client who has cancer and is experiencing breakthrough pain. Which ofthe following prescriptions should the nurse anticipate?a. Transmucosal fentanylb. Intramuscular meperidinec. Oral acetaminophend. Intravenous dexamethasoneRationale: ATI pg. 27 Morphine sulfate and fentanyl are opioid agents used to treat moderate to severe pain. Ashort-acting pain medication is administered for breakthrough pain.6. A nurse is admitting a client who reports chest pain and has been placed on a telemetry monitor. Which of thefollowing should the nurse analyze to determine whether the client is experiencing a myocardial infarction?a. PR intervalb. QRS durationc. T waved. ST segmentRationale: ST elevation indicates MI. ST depression indicates ischemia7. A nurse is teaching a client who has ovarian cancer about skin care following radiation treatment. Which of thefollowing instructions should the nurse include?a. Pat the skin on the radiation site to dry itb. Apply OTC moisturizer to the radiation sitec. Cover the radiation site loosely with a gauze wrap before dressingd. Use a soft washcloth to clean the area around the radiation site Rationale: pg. 584. Dry the area thoroughly using patting motions.8. A nurse is caring for a client who is receiving a blood transfusion. The nurse observes that the client hasbounding peripheral pulses, hypertension, and distended jugular veins. The nurse should anticipate administering which ofthe following prescribed medications?a. Diphenhydramineb. Acetaminophenc. Pantoprazoled. FurosemideRationale: S/S may indicate fluid retention or heart failure. It is important to administer diuretics to prevent cardiovascular/respiratory distress.9. A nurse is assessing a client who is receiving magnesium sulfate IV for the treatment of hypomagnesemia.Which of the following findings indicates effectiveness of the medication?a. Lungs clearb. Apical pulse 82/minc. Hyperactive bowel soundsd. Blood pressure 90/50 mm HgRationale: pg. 278 Confirmed on answer sheet10. A nurse is reviewing a client’s ABG results pH 7.42, PaC02 30 mm Hg, and HCO3 21 mEq/L. The nurse should recognizethese findings as indication of which of the following conditions?a. Metabolic acidosisb. Metabolic alkalosisc. Compensated respiratory alkalosisd. Uncompensated respiratory acidosisRationale: because the HCO3 21 trying to compensate for respiratory alkalosis.11. A nurse is caring for a client who has a deep partial thickness burns over 15% of her body which of the following labs should the nurse expect during the first 24 hoursA. Decreased BUN (elevated due to fluid loss)B. Hypoglycemia (High due to stress)C. Hypoalbuminemia (Low due to fluid loss)D. Decreased Hematocrit (Elevated due to 3rd spacing during resuscitation phase) Rationale: Pg. 481 ATI. Total protein and albumin- low due to fluid loss.12. A nurse is caring for a client who has dumping syndrome following a gastrectomy, which of the following actions shouldthe nurse takes?a. Offer the client high carbohydrate meal options (High fat, high protein, low fiber, low to moderate carbs page 317, chapter 49 Peptic ulcer disease med surg ATI PDF 10.0)b. Provide the client with four full meals a day (Small frequent meals)c. Encourage the client to drink at least 360 ml of fluids with meals (Eliminate liquids with meals for 1 hr. prior and following a meal)d. Have the client lie down for 30 minutes after meals (Lying down after a meal slows the movement of food within the intestines)Rationale: ATI pg. 318 Dumping syndromes is a term that refers to a constellation of vasomotor symptoms that occurs after eating, especially following a Billroth II procedure. Early manifestations usually occur within 30 minutes of eating and include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. The nurse should instruct the client to decrease theamount of fluid taken at meals and to avoid high-carbohydrate foods, including fluids such as fruit nectars; to assume a low-Fowler's position during meals; to lie down for 30 minutes after eating to delay gastric emptying; and to take antispasmodics as prescribed.12. A nurse is teaching a group of young adult clients about risk factors for hearing loss. Which of the following factors shouldthe nurse include in the teaching?a. Born with a high weightb. Chronic infections of the middle earc. Use a loop diuretic such as furosemide and antibiotics like aminoglycoside and gentamicin leads to ototoxic medicationd. Perforation of the eardrume. Frequent exposure to low volume noiseRationale: Peds ATI pg. 77Exposure to loud environmental sounds. Hearing defects can be caused by a variety