ATI Med Surg Online Practice A and B with rationales.docx

A nurse is caring for a client following excavation

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a nurse is caring for a client following excavation of her endotracheal tube 10 minutes ago. Which of the following findings should the nurse report to the provider immediately Strider. Using the Urgent vs. Non-urgent approach to client care the nurse should determine that the priority finding a Strider. Strider can indicate and narrowing Airway or possible obstruction caused by edema or laryngeal spasms the nurse should report the finding immediately Implement an intervention a nurse is caring for a client who had a nephrostomy tube inserted 12 hours ago. Which of the following findings should the nurse report to the provider The client reports back pain the nurse should notify the provider if the client reports back pain which can indicate that the nephrostomy tube is dislodged or clogged A nurse is assessing a client while suctioning the clients tracheostomy tube which of the following findings should indicate to the nurse that the client is experiencing hypoxia The clients heart rate increases because hypoxia related to suctioning can cause the clients heart rate to increase if this occurs the nurse should discontinue the sectioning
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and immediately oxygenate the client with 100% oxygen the nurse should instruct the client to take three or four deep breaths prior to suctioning to reduce the risk for hypoxia A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish and ureterostomy. Which of the following statements should the nurse include in the teaching Cut the opening of The Skin Barrier one eighth of an inch wider than the stoma. The client should cut the opening of The Skin Barrier 1/8 inch wider than the stoma to minimize irritation of the skin from exposure to urine A nurse is teaching a client who has atrial fibrillation about the purpose of wearing a Holter monitor. Which of the following information should the nurse include in the teaching This device can detect when you have an irregular heart rate because it reports and transmits electrical impulses of the heart and alerts the nurse to dysrhythmias myocardial injury or conduction defects a Holter monitor allows the client freedom of movement while cardiac activity is recorded A nurse is providing discharge teaching to a client who has heart failure and a new prescription for potassium sparing diuretic which of the following information should the nurse include in the teaching Try to walk at least 3 times per week for exercise because the development of a regular exercise routine can improve outcomes in clients who have heart failure A nurse is caring for a client who has chronic glomerulonephritis with oliguria which of the following findings should the nurse identify as a manifestation of chronic glomerulonephritis Hyperkalemia as a result of kidney failure because kidney failure results in decreased excretion of potassium A nurses in an acute care facility is caring for a client who is at risk for seizures which of the following precautions should the nurse implement
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