MED SURG PRIORITY TWO 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 Heart rate 90 min Absent bowel sounds Hgb 8 2 g dl Gastric pH of 3 0 Rationale Normal Hgb is 13 18M g dl 12 16 g dl This may indicate a possible hemorrhaging A nurse is caring for a client who has diabetes insipidus Which of the following medications should the nurse plan to 1 a b c d 2 administer a b c d on urinating Desmopressin Regular insulin Furosemide Lithium carbonate 3 Which of the following test should the nurse monitor a b c d Stool for occult blood GI bleed Fasting blood glucose tarry stools abdominal pain Rationale Diabetes Insipidus has decreased ADH Administer Desmopressin Vasopressin increase ADH and to stop patient A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily for 3 years Urine for white blood cells Serum calcium Rationale ATI Pharm 16 Pg 485 Ibuprofen NSAIDs monitor for GI bleed bloody 4 A nurse in the emergency department is assessing a client Which of the following actions should the nurse take first Click on the Exhibit button for additional information about the client There are three tabs that contain separate categories of data a b c d Obtain a sputum sample for culture Prepare the client for a chest x ray Initiate airborne precautions Administer ondansetron Rationale No idea what the Exhibit is all about won t be able to answer it A nurse is contacting the provider for a client who has cancer and is experiencing breakthrough pain Which of 5 the following prescriptions should the nurse anticipate a b c d Transmucosal fentanyl Intramuscular meperidine Oral acetaminophen Intravenous dexamethasone Rationale ATI pg 27 Morphine sulfate and fentanyl are opioid agents used to treat moderate to severe pain A short acting pain medication is administered for breakthrough pain A nurse is admitting a client who reports chest pain and has been placed on a telemetry monitor Which of the 6 following should the nurse analyze to determine whether the client is experiencing a myocardial infarction a b c d PR interval QRS duration T wave ST segment Rationale ST elevation indicates MI ST depression indicates ischemia A nurse is teaching a client who has ovarian cancer about skin care following radiation treatment Which of the 7 following instructions should the nurse include a b c d site Rationale pg 584 Dry the area thoroughly using patting motions Pat the skin on the radiation site to dry it Apply OTC moisturizer to the radiation site Cover the radiation site loosely with a gauze wrap before dressing Use a soft washcloth to clean the area around the radiation 8 A nurse is caring for a client who is receiving a blood transfusion The nurse observes that the client has bounding peripheral pulses hypertension and distended jugular veins The nurse should anticipate administering which of the following prescribed medications a b c d Diphenhydramine Acetaminophen Pantoprazole Furosemide Rationale S S may indicate fluid retention or heart failure It is important to administer diuretics to prevent cardiovascular respiratory distress A nurse is assessing a client who is receiving magnesium sulfate IV for the treatment of hypomagnesemia 9 Which of the following findings indicates effectiveness of the medication a b c d Lungs clear Apical pulse 82 min Hyperactive bowel sounds Blood pressure 90 50 mm Hg Rationale pg 278 Confirmed on answer sheet A nurse is reviewing a client s ABG results pH 7 42 PaC02 30 mm Hg and HCO3 21 mEq L The nurse should recognize 10 these findings as indication of which of the following conditions a b c d Metabolic acidosis Metabolic alkalosis Compensated respiratory alkalosis Uncompensated respiratory acidosis Rationale because the HCO3 21 trying to compensate for respiratory alkalosis A nurse is caring for a client who has a deep partial thickness burns over 15 of her body which of the following 11 labs should the nurse expect during the first 24 hours Decreased BUN elevated due to fluid loss A B Hypoglycemia High due to stress C Hypoalbuminemia Low due to fluid loss D phase Rationale Pg 481 ATI Total protein and albumin low due to fluid loss Decreased Hematocrit Elevated due to 3rd spacing during resuscitation Provide the client with four full meals a day Small frequent meals Offer the client high carbohydrate meal options High fat high protein low fiber low to moderate carbs A nurse is caring for a client who has dumping syndrome following a gastrectomy which of the following actions should 12 the nurse takes a page 317 chapter 49 Peptic ulcer disease med surg ATI PDF 10 0 b c prior and following a meal d 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 the Encourage the client to drink at least 360 ml of fluids with meals Eliminate liquids with meals for 1 hr Have the client lie down for 30 minutes after meals Lying down after a meal slows the movement of amount 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 A nurse is teaching a group of young adult clients about risk factors for hearing loss Which of the following factors should 12 the nurse include in the teaching a b c d e Born with a high weight Chronic infections of the middle ear Use a loop diuretic such as furosemide and antibiotics like aminoglycoside and gentamicin leads to ototoxic medication Perforation of the eardrum Frequent exposure to low volume noise Rationale Peds ATI pg 77 Exposure to loud environmental sounds Hearing defects can be caused by a variety of conditions including anatomic malformation maternal ingestion of toxic substances during pregnancy perinatal asphyxia perinatal infection chronic ear infection and ototoxic medications A nurse is preparing to administer fresh frozen plasma to a client Which of the following actions should the nurse take Administer the plasma immediately after thawing