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ATI Medical-Surgical CMS Review TEST BANK 2022

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ATI Medical-Surgical CMS Review TEST BANK 2022

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  • August 19, 2022
  • 40
  • 2022/2023
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ATI Medical-Surgical CMS Review TEST BANK 2022

NURSE IS PLANNING CARE FOR CLIENT WHO IS POST-OP FOR RADICAL MASTECTOMY - NURSING
INTERVENTIONS Correct Answer: begin exercises with the client 1 day after procedure

exercises that do not stress the incision site can promote lymphatic return and mobility

PRE-OPERATIVE TEACHING FOR A CLIENT SCHEDULED FOR TOTAL KNEE ARTHROPLASTY Correct Answer:
elastic stockings worn after surgery will help prevent venous embothrobolism

BLADDER CANCER - HIGHEST RISK FACTOR Correct Answer: tobacco use

CARDIAC CATHETERIZATION - PREPROCEDURE CLIENT TEACHING Correct Answer: client should remain
flat for 2-6 hours following procedure

client will receive mild sedative for relaxation/comfort

client will need to keep the leg straight following the procedure

CLIENT IS BEING ADMITTED WITH FREQUENT COUGHING, FROTHY PINK SPUTUM. CLIENT HAS Hx OF
NIGHT SWEATS, ANOREXIA, AND WEIGHT LOSS - PRIORITY NURSING ACTIONS Correct Answer: assign
the client to a private, NEGATIVE-PRESSURE room

initiate AIRBORNE precautions

wear N95 mask when entering client's room

PLANNING CARE FOR A CLIENT WHO HAS DEEP PARTIAL-THICKNESS BURNS OVER 40% OF HIS BODY AND
IN THE ACUTE PHASE OF BURN INJURY - NURSING INTERVENTION THAT SHOULD BE INCLUDED IN THE
PLAN OF CARE Correct Answer: begin performing active/passive range of motion exercises with client

maintains mobility and prevents contractures

RIFLE CLASSIFICATION OF AKI - RISK Correct Answer: < 0.5 mL/kg/hr of urine output for 6 hours

RIFLE CLASSIFICATION OF AKI - INJURY Correct Answer: < 0.5 mL/kg/hr of urine output for 12 hours

RIFLE CLASSIFICATION OF AKI - FAILURE Correct Answer: no urine (anuria) output for 12 hours

or

< 0.3 mL/kg/hr for 24 hours

RIFLE CLASSIFICATION OF AKI - LOSS Correct Answer: no urine output without renal replacement
therapy for 4 to 12 weeks

,RIFLE CLASSIFICATION OF AKI - END STAGE RENAL FAILURE Correct Answer: no urine output without
renal replacement therapy for more than 3 months

ACUTE INTRAVASCULAR HEMOLYTIC REACTION - ASSESSMENT FINDING Correct Answer: sudden
oliguria

this type of transfusion reaction causes acute kidney injury (AKI) resulting in sudden oliguria and
hemoglobinuria

NURSING IS PLANNING CARE FOR CLIENT WITH SIADH WITH MILD SYMPTOMS - RX THAT WILL BE
ANTICIPATED Correct Answer: tolvaptan (Samsca)

this Rx is a vasopressin antagonist that promotes the excretion of water

corrects the fluid imbalance in clients who have SIADH

CHLORPROPAMIDE Correct Answer: anti-diabetic agent with antidiuretic effects

used to treat diabetes insipidus

VASOPRESSIN Correct Answer: exogenous form of antidiuretic hormone

used to treat diabetes insipidus

DEMOPRESSIN Correct Answer: synthetic form of antidiuretic hormone

used to treat diabetes insipidus

LASIK SURGERY - ADVERSE EFFECT Correct Answer: dry eyes

blurred vision

LASIK SURGERY Correct Answer: procedure that can correct:
- nearsightedness
- farsightedness
- astigmatism

changes the shape of the cornea to correct vision

CLIENT WITH BELOW-THE-KNEE AMPUTATION WHO IS 3 DAYS POSTOPERATIVE - NURSING ACTION
Correct Answer: rewrap the residual limb with a pressure bandage 3x daily

this ensures the residual limb will shrink

also provides an opportunity to assess the skin for redness/breakdown

THEOPHYLLINE TOXICITY - ASSESSMENT FINDING Correct Answer: tremors

,an early manifestation of toxicity is CNS stimulation, often seen as tremors

seizures can occur if blood levels continue to rise

STAGE I PRESSURE ULCER Correct Answer: skin is intact, with an area of persistent, non-blanchable
redness

usually over a bony prominence

STAGE II PRESSURE ULCER Correct Answer: involves partial-thickness skin loss of the epidermis and
dermis

ulcer is visible and superficial

can look like an abrasion, blister, or shallow crater

STAGE III PRESSURE ULCER Correct Answer: involves full thickness tissue loss with damage or necrosis of
subcutaneous tissue

damage might extend down to, BUT NOT THROUGH the underlying fascia

looks like a deep crater

STAGE IV PRESSURE ULCER Correct Answer: full thickness tissue loss

visible damage to muscle, bone and supporting structures

sinus tracts, deep pockets of infection and tunneling may occur

PERIPHERAL VASCULAR DISEASE - ASSESSMENT FINDINGS Correct Answer: ankle swelling

skin is warm to touch

skin appears thick/brownish

hair is present

ulcers appear moist/bleeding

edges of ulcers are uneven

LIVER BIOPSY - LAB TO MONITOR PRIOR TO PROCEDURE Correct Answer: prothrombin time

major complication of liver biopsy is hemorrhage

clients who have liver disease have clotting factor defects and increased risk for bleeding

, LUMBAR PUNCTURE FOR CLIENT WHO HAS MANIFESTATIONS OF BACTERIAL MENINGITIS - EXPECTED
LAB FINDINGS Correct Answer: elevated protein

elevated WBC

decreased glucose

elevated CSF pressure

cloudy CSF

CLIENT IS RECEIVING CHEMOTHERAPY - ADVERSE EFFECTS THAT THE NURSE SHOULD ANTICIPATE
Correct Answer: pancytopenia

pancytopenia (deficiency of WBCs, RBCs, and platelets) is an expected adverse effect of chemotherapy

HETEROGRAFT DRESSINGS ARE OBTAINED FROM... Correct Answer: pig skin

heterografts are obtained from an animal, usually a pig

CLIENT IS SCHEDULED TO HAVE ARTHROSCOPY - STATEMENT THAT INDICATES CLIENT UNDERSTANDS
THE PREPROCEDURE TEACHING Correct Answer: "the doctor will be able to see if I have signs of
rheumatoid arthritis"

arthroscopy helps with diagnosing musculoskeletal disorders such as rheumatoid arthritis, osteoarthritis
and internal joint injuries

A NURSE IS ASESSSING FOR DISSEMINATED INTRAVASCULAR COAGULATION (DIC) IN A CLIENT WITH
SEPTIC SHOCK SECONDARY TO AN UNTREATED FOOT WOUND - EXPECTED ASSESSMENT FINDINGS
Correct Answer: bleeding at the venipuncture site

petechiae on chest and arms

abdominal distension (due to internal bleeding)

PROBENICID - DRUG INTERACTION Correct Answer: aspirin

aspirin decreases effectiveness of probenecid

A NURSE IS ADMITTING A CLIENT WHO HAS CIRRHOSIS - PRESCRIPTIONS THAT THE NURSE SHOULD
ANTICIPATE Correct Answer: obtain client's PT/INR

administers lactulose 30 mL 4x/day

obtain daily weight and abdominal girth measurement

administer a daily vitamin

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