ATI MED SURG VERSION 8 EXAM

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.