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ATI Medical Surgical Proctored Exam 2019 Quizlet
1. The client is prescribed clozapine (Clozaril), and the nurse plans to educate them about its purpose. Which statement should the nurse provide?
- A. It will help you function better in the community.
- B. The medication will help you think more clearly.
- C. You will be able to cope with your symptoms.
- D. It will improve your grooming and hygiene.
Correct answer: B
Rationale: Clozapine (Clozaril) is an antipsychotic medication that is known to improve cognitive function and thought clarity in individuals with schizophrenia. It primarily helps in managing symptoms related to thought processes rather than focusing on community function, coping with symptoms, or grooming and hygiene.
2. In planning the turning schedule for a bedfast client, it is most important for the nurse to consider what assessment finding?
- A. 4+ pitting edema of both lower extremities.
- B. A Braden risk assessment scale rating score of ten.
- C. Warm, dry skin with a fever of 100° F.
- D. Hypoactive bowel sounds with infrequent bowel movements.
Correct answer: B
Rationale: A low Braden score indicates a high risk for pressure ulcers, making regular turning crucial to prevent skin breakdown.
3. The client with newly diagnosed osteoporosis is being taught by the nurse about dietary modifications. Which instruction should the nurse include?
- A. Increase your intake of high-calcium foods.
- B. Limit your intake of vitamin D-rich foods.
- C. Avoid foods high in phosphorus.
- D. Increase your intake of high-sodium foods.
Correct answer: A
Rationale: Increasing the intake of high-calcium foods is essential for improving bone density and managing osteoporosis. Calcium is a key mineral necessary for bone health, and individuals with osteoporosis often need higher levels of calcium to help strengthen their bones and prevent further bone loss. Therefore, advising the client to increase their intake of high-calcium foods is the most appropriate dietary modification to support their bone health.
4. A male client is admitted to the neurological unit. He has just sustained a C-5 spinal cord injury. Which assessment finding of this client warrants immediate intervention by the nurse?
- A. Is unable to feel sensation in the arms and hands.
- B. Has flaccid upper and lower extremities.
- C. Blood pressure is 110/70 and the apical pulse is 68.
- D. Respirations are shallow, labored, and 14 breaths/minute.
Correct answer: D
Rationale: Respirations that are shallow, labored, and at 14 breaths/minute indicate potential respiratory compromise, which is a critical situation requiring immediate intervention to maintain adequate oxygenation and prevent respiratory failure.
5. A client with chronic kidney disease (CKD) has an arteriovenous (AV) fistula for hemodialysis. Which finding should the nurse report to the healthcare provider immediately?
- A. No bruit or thrill over the AV fistula.
- B. Redness at the site of the AV fistula.
- C. Client's complaint of pain at the AV fistula site.
- D. Swelling of the hand on the side of the AV fistula.
Correct answer: A
Rationale: In a client with a chronic kidney disease who has an arteriovenous (AV) fistula for hemodialysis, the absence of a bruit (a humming sound) or thrill (vibratory sensation) over the AV fistula indicates a potential occlusion. This finding suggests inadequate blood flow through the AV fistula, which is a critical issue requiring immediate intervention to prevent complications such as thrombosis or clot formation. Reporting this absence of bruit or thrill promptly to the healthcare provider is essential to ensure timely assessment and management to maintain vascular access for hemodialysis.
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