ATI Medical Surgical Assessment F
1. A nurse is caring for a client with a history of congestive heart failure at risk for development of fluid volume excess. The nurse should monitor for which of the following that is a manifestation of left-sided heart failure?
• Swelling of the fingers and...
1. A nurse is caring for a client with a history of congestive heart failure at
risk for development of fluid volume excess. The nurse should monitor for
which of the following that is a manifestation of left-sided heart failure?
• Swelling of the fingers and hands
• Jugular neck vein distension
• 3+ ankle edema
• Dyspnea with a cough that is worse at night - Dyspnea with a cough that
is worse at night is an indication of left-sided heart failure. Left-sided heart
failure causes blood to back up in the heart and lungs with decreased
distribution of blood throughout the body.
2. Which client problem should receive highest priority when a client is
admitted with an acute exacerbation of rheumatoid arthritis?
• Difficulty with hygiene and grooming
• Impaired physical mobility - When setting priorities for nursing care,
physiological needs should be addressed first according to Maslow's
Hierarchy of Needs. Reducing the client's pain will help with other needs,
such as hygiene and grooming.
• Body-image disturbance
• Anxiety
,3. A nurse is caring for a client with hypoparathyroidism. Because of the
potential electrolyte disturbance associated with this diagnosis, the nurse
should observe the client for evidence of which of the following?
• Elevated blood pressure
• Involuntary muscle spasms - A decrease in parathormone secretion leads
to hypocalcemia (decreased serum calcium levels), which may cause tetany.
Involuntary muscle spasms are a common symptom associated with
hypoparathyroidism.
• Cold intolerance
• Weight loss
4. A client with glaucoma is admitted for surgery the following day. The client
is to continue treating the glaucoma with pilocarpine (Pilocar) 2% 1 drop 4
times a day. While instilling this medication, an appropriate nursing action is
which of the following?
• Instruct the client to blink several times after instillation of the medication.
• Ask the client to look straight ahead.
• Place the medication in the conjunctival sac applying pressure to the
puncta for 1 to 2 min. - Eye drops are instilled into the conjunctival sac
and pressure applied to the puncta for 1 to 2 min to prevent loss of
medication into the nasal lacrimal duct and into the systemic circulation.
• Dab excess medication from the eye using a cotton ball 10 to 15 seconds
after instillation.
, 5. A client has sprained an ankle while playing soccer. For the first 24 hr
following the injury, the nurse should instruct the client to do which of the
following?
• Perform gentle range of motion (ROM) exercises on the ankle joint to
prevent contractures.
• Keep moist heat on the ankle to prevent muscle spasm.
• Keep the foot in a dependent position to aid circulation to the foot.
• Keep ice on the ankle to prevent edema. - Ice or cold will constrict blood
vessels to the injured area decreasing swelling. Nerve impulse transmission
will also be reduced, resulting in analgesia to the injured area and a
reduction of muscle spasms. Ice applications should not exceed 20 to 30 min
per application.
6. A nurse is assisting with the discharge of a client newly diagnosed with
diabetes. When reviewing information about proper foot care, which of the
following would be appropriate to include?
• Soak feet every night in warm water.
• Wear clean cotton socks daily. - Cotton socks should be worn by clients
who are diabetic. They are soft and will wick excess moisture away from the
foot.
• Walk barefoot at home when possible.
• Get fitted for shoes in the morning.
7. Following a transient ischemic attack (TIA), a client is alert, slightly
confused, and has a blood pressure of 204/102 mm Hg. The client is also
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller TheStudyAce. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $10.59. You're not tied to anything after your purchase.
