ATI NCLEX Medical Surgical Assessment 1 (Top 2024/2025 EXAM REVIEW DOC )

ATI NCLEX Medical Surgical Assessment 1 A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following actions should the nurse include in the plan A. Provide the client with a means of communication B. Maintain the head of the client's bed in a flat position C. Suction the client's endotracheal tube every 4 hr D. Perform oral hygiene for the client every 8 hr - A Use electronic tablet computer, programmable speech generating device, alphabet board, pencil and paper, etc -- B, keep head of bed higher than 30 degrees to prevent aspiration and ventilator associated pneumonia. Turn the client q 2hr to prevent complications related to immobility C, assess the need to suction q 2-4 hr, but not perform routine suctioning. Base the need for suctioning on assessments, not a schedule. Unnecessary suctioning can cause bronco spasms and injury tracheal mucosa D, oral hygiene should be performed q 2 hr to decrease the risk of ventilator associated pneumonia A nurse is caring for a client who is receiving IV fluid replacement therapy for dehydration. Which of the following laboratory results indicates effectiveness of the treatment A. Sodium 165 mEq/L B. Potassium 5.2 mEq/L C. Urine specific gravity 1.020 D. Hct 62% - C Within the expected range of 1.005-1.030 -- A, sodium range is 136-145 B, potassium range is 3.5-5 D, Hct range is 37%-52% A nurse is monitoring the laboratory findings for a client who is postoperative following a total hip arthroplasty 6 hr ago. Which of the following values indicates that the client has an increased risk for bleeding A. PT 11.5 seconds B. aPTT 35 seconds C. Platelets 80,000 D. RBC 4.0 million - C platelet range is 150,000-400,000 -- A, PT range is 11-12.5 B, aPTT range is 30-40 seconds D, RBC range is 4.2-6.1 million. A low RBC can indicate that bleeding has occurred, but it does not indicate that the client is at risk for bleeding A nurse is admitting a client who has a cervical spinal cord injury following a motor vehicle crash. Which of the following interventions is the nurse's priority while caring for this client A. Change the client's position every 2 hours B. Pad pressure points at the edges of