ATI MED SURG VERSION 8 EXAM
A nurse is admitting a client who is suspected having active tuberculosis (TB). Which of
the following actions should the nurse take first? (chap. 20)
a) Administer antituberculosis medication.
b) Institute airborne precautions.
c) Obtain sputum cultures.
d) Auscultate breath sounds. - ANSWERB
The greatest risk from this client is transmitting TB to
staff and other clients. Therefore, the first action the nurse should take is to implement
airborne precautions.
A nurse is caring for a client who is postoperative and has a Jackson-Pratt drain. Which
of the following actions should the nurse take?
a) Fill the bulb reservoir with 0.9% sodium chloride.
b) Allow the Jackson-Pratt drain to hang freely.
c) Cut a slit in a gauze sponge and apply it around the tubing insertion site.
d) Compress the bulb reservoir and then close the drainage valve. - ANSWERD
(The nurse should fully
compress the bulb reservoir and then replace the valve plug using aseptic technique to
establish suction after emptying or activating a Jackson-Pratt drain.)
A nurse is reinforcing teaching with the parent of a toddler who has type I diabetes
mellitus and whose prescription has been changed from regular insulin to lispro insulin.
Which of the following information should the nurse include in the teaching?
a) Lispro is given once a day.
b) Lispro should be given before eating
c) Lispro cannot be given with other insulin.
d) Lispro does not cause hypoglycemia. - ANSWERB
(Lispro insulin should be given around mealtime,
A nurse is reinforcing teaching with a client who has microcytic anemia and is
prescribed a daily iron supplement. The nurse tells the client to consume foods
containing vitamin C when taking the supplement to enhance iron absorption. Which of
the following client food choices indicates an understanding of the teaching?
a) 1 cup cooked brown rice
b) 1 cup boiled broccoli
c) 1 cup cottage cheese
d) 1 cup cooked kidney beans - ANSWERB
A nurse is reinforcing teaching with an older adult client who has osteoporosis. Which of
the following instructions should the nurse in the teaching?
a) "Place throw rugs on wooden floors at home."
b) "Supplement your diet with vitamin E."
c) "Swim laps for 20 minutes twice per week."
d) "Take calcium supplements with meals." - ANSWERD
The nurse should instruct the client to take
calcium carbonate supplements with or following meals to increase absorption and
effectiveness.
A nurse is reviewing the medication record of a client who is taking digoxin. Which of
the following medications should the nurse identify as increasing the risk for the client to
develop digoxin toxicity?
a) Potassium chloride
b) Famotidine
c) Levothyroxine
d) Furosemide - ANSWERD
The nurse should identify that loop diuretics, such as furosemide, increase
the urinary excretion of potassium, which can lead to hypokalemia. Hypokalemia
increases the risk for the development of digoxin toxicity.
A nurse is reinforcing teaching about insulin injections with an adult client who weighs
45.4 kg (100 lb.). Which of the following statements by the client indicates an
understanding of the teaching?
a) "I should insert the needle at a 90-degree angle."
b) "I should give my shot in my belly tissue."
c) "I will pull back on the syringe plunger to look for blood before I push the medication
in."
d) "I will use the side of my hand to pull my skin to the side prior to administering the
insulin." - ANSWERB
Clients who have low body weights can
have very little subcutaneous tissue. Therefore, the nurse should instruct the client to
administer the medication in the upper abdomen for proper absorption.