RN Adult Medical Surgical Online Practice 2022 ATI A
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Course
NURS 1538
Institution
NURS 1538
A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following
laboratory findings should the nurse expect?
A nurse and an assistive personnel (AP) are caring for a client who has bacterial meningitis. The
nurse should give the AP which of the following
instructions?...
rn adult medical surgical online practice 2022 ati a
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RN Adult Medical Surgical Online Practice 2022 ATI A
A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following
laboratory findings should the nurse expect?
• Negative urine ketones – INCORRECT
o A client who has DKA experiences ketosis, which results in ketones in the urine
and blood.
• BUN 32 mg/dL – CORRECT
o DKA results in osmotic diuresis and subsequent dehydration. The nurse should
expect a client who has DKA to have elevated BUN, creatinine, and specific
gravity levels resulting from the excess glucose present in the urine.
• pH 7.43 – INCORRECT
o The nurse should expect a client who has DKA to have a pH level less than 7.35
due to the increased production of ketones, which results in metabolic acidosis.
The client might exhibit Kussmaul respirations, which are deep and rapid
respirations that compensate for the decreased pH. Sodium bicarbonate is
administered for severe acidosis when the client's pH level is less than 7.O
• HCO3 23 mEq/L – INCORRECT
o The nurse should expect a client who has DKA to have an HCO3 less than 15
mEq/L. This decreased value is due to an increased production of ketones,
resulting in metabolic acidosis.
A nurse and an assistive personnel (AP) are caring for a client who has bacterial meningitis. The
nurse should give the AP which of the following
instructions?
• Wear a mask – CORRECT
o Bacterial meningitis requires droplet precautions; therefore, the AP and the
nurse should wear a mask when coming within 0.9 m (3 ft) of the client until 24
hr after the client has begun receiving antibiotic therapy.
• Wear a gown – INCORRECT
o A gown is necessary when caring for clients who require contact precautions.
Bacterial meningitis does not spread via direct contact.
• Keep the client's room well-lit – INCORRECT
o Staff caring for this client should keep the illumination in the room dim and avoid
bright light from windows to promote comfort and rest and avoid photophobia.
• Maintain the head of the bed at a 45° elevation – INCORRECT
o Staff caring for this client should keep the head of the bed at a 30° elevation.
A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new
prescription for metformin. Which of the following
statements by the client indicates an understanding of the teaching?
o "I will monitor my blood sugar carefully because the medication increases the secretion
of insulin." – INCORRECT
, o Metformin decreases the amount of glucose produced in the liver and increases
tissue sensitivity to insulin.
o "I should take this medication with a meal."- CORRECT
o The client should take metformin with or immediately following meals to
improve absorption and to minimize gastrointestinal distress.
o "I can expect to gain weight while taking this medication." – INCORRECT
o Typically, clients lose weight when beginning to take metformin due to nausea
and vomiting.
o "While taking this medication, I will experience flushing of my skin." – INCORRECT
o Flushing of the skin is not an adverse effect of metformin.
A nurse in a provider's office is assessing a client who has hypertension and takes propranolol.
Which of the following findings should indicate to the nurse that the client is experiencing an
adverse reaction to this medication?
o Report of a night cough – CORRECT
o The nurse should recognize that a night cough is an early indication of heart
failure and report this adverse reaction to the provider.
o Report of tinnitus – INCORRECT
o Propranolol is a nonselective beta-adrenergic antagonist that has sensory effects,
including dry eyes and vision changes. However, tinnitus is not an adverse effect
of propranolol.
o Report of excessive tearing – INCORRECT
o Propranolol is a nonselective beta-adrenergic antagonist that can affect the
heart, the lungs, and the eyes. Ophthalmic adverse effects include blurred vision
and any eyes
o Report of increased salivation – INCORRECT
o Propranolol is a nonselective beta-adrenergic antagonist that has several
gastrointestinal effects, such as dry mouth, abdominal cramping, constipation,
and diarrhea.
A nurse is caring for a client who has a leg cast and is returning demonstration on the proper
use of crutches while climbing stairs. Identify the sequence the client should follow when
demonstrating crutch use.
o Places body weight on the crutches
o Advances the unaffected leg onto the stair
o Shifts weight from the crutches to the unaffected leg
o Brings the crutches and the affected leg up to the stair
o The client should first place their body weight on the crutches. Next, they should
advance the unaffected leg onto the stair. Third, they should shift their weight
from the crutches to the unaffected leg. Last, they should bring the crutches and
the affected leg up to the stair.
,A nurse in an emergency department is caring for a client who is experiencing a thyroid storm.
Which of the following manifestations should the nurse expect? (SATA)
o Fever
o Nonpitting edema
o Hypertension
o Tachycardia
o Hypoglycemia
o Fever is correct. The nurse should expect the client to have a fever because of
the excessive thyroid hormone release. Nonpitting edema is incorrect. Nonpitting
edema is a manifestation of myxedema coma, a complication of hypothyroidism.
Hypertension is correct. The nurse should expect one of the early manifestations
of thyroid storm to include systolic hypertension because of the excessive thyroid
hormone release. Tachycardia is correct. The nurse should expect the client to
have tachycardia because of the excessive thyroid hormone release
Hypoglycemia is incorrect. Hypoglycemia is a manifestation of myxedema coma,
a complication of hypothyroidism.
A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a productive
cough. Which of the following actions should the nurse take first?
o Obtain a sputum sample – INCORRECT
o The nurse should obtain a sputum sample to identify the micro-organisms that
are causing the client's illness. However, there is another action that the nurse
should take first.
o Administer antipyretics – INCORRECT
o The nurse should administer antipyretics to treat the client's fever. However,
there is another action that the nurse should take first.
o Provide hand hygiene education – INCORRECT
o The nurse should provide hand hygiene education. However, there is another
action that the nurse should take first.
o Initiate airborne precautions – CORRECT
o This client is exhibiting manifestations of tuberculosis. The greatest risk in this
client situation is for other people in the facility to acquire an airborne disease
from this client. Therefore, the first action the nurse should take is to initiate
airborne precautions.
A nurse is caring for a client who has a closed head injury and has an
intraventricular catheter placed. Which of the following findings
indicates that the client is experiencing increased intracranial pressure
(ICP)? (SATA.)
o Flat jugular veins
o A Glasgow Coma Scale score of 15
o Sleepiness exhibited by the client
o Widening pulse pressure
, o Decerebrate posturing
o Flat jugular veins is incorrect. With increased ICP, the
jugular veins are typically distended. A Glasgow Coma Scale
score of 15 is incorrect. A Glasgow Coma Scale score of 15
indicates neurological functioning within the expected
reference range for eye opening, motor, and verbal
response. Sleepiness exhibited by the client is correct.
Sleepiness or difficulty arousing the client from sleep is an
indication of increased ICP.
Widening pulse pressure is correct. A widening pulse
pressure (increase in systolic with concurrent decrease in
diastolic blood pressure) is an indication of increased 1CP.
Decerebrate posturing is correct. Both decerebrate and
decorticate posturing indicate increased ICP.
A nurse is caring for a client who is having a seizure. Which of the
following interventions is the nurse's priority?
o Loosen the clothing around the client's neck – INCORRECT
o The nurse should loosen any restrictive clothing the client is
wearing to prevent injury to the client. However, another
action is the priority.
o Check the client's pupillary response – INCORRECT
o The nurse should perform neurologic checks after the
seizure to monitor the client's recovery. However, another
action is the priority.
o Turn the client to the side – CORRECT
o The greatest risk to this client is hypoxia from an impaired
airway. Therefore, the priority intervention the nurse should
take is to place the client in a side-lying position to prevent
aspiration.
o Move furniture away from the client – INCORRECT
o The nurse should move furniture away from the client to
prevent self-injury. However, another action is the priority.
A nurse is providing discharge instructions to a client who has a partial-
thickness burn on the hand. Which of the following instructions should
the nurse include?
o Change the dressing every 72 hr – INCORRECT
o The nurse should instruct the client to change the dressing
every 12 to 24 hr to allow for wound inspection. The client
should observe the wound closely for manifestations of
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