ATI NCLEX Medical Surgical Assessment 1 Questions with Complete Answers

A nurse is caring for a client who is receiving a blood transfusion. Which of the following findings indicates that the client is experiencing transfusion-associated circulatory overload A. Nasuea B. Hypothermia C. Dyspnea D. Bradycardia - C Dyspnea is an indication of possible transfusion associated circulatory overload, leading to hypertension, bounding pulses, and confusion. Dyspnea can also indicate transfusion related acute lung injury to an anaphylactic response, which also causes wheezing, chest tightness, cyanosis, and low BP -- A, nausea can indicate an acute hemolytic transfusion reaction B, transfusion reactions include acute hemolytic, febrile, mild allergic, and anaphylactic D, bradycardia is not an indication A nurse is assessing a client who has lung cancer and is undergoing radiation therapy to the chest. Which of the following indicates an adverse effect of the therapy A. Hair loss on the scalp B. Sweating at the treatment site C. Altered taste sensations D. Intolerance to cold - C Altered taste is a result of the release of metabolites by dead cells -- A, client may have hair loss at the treatment site on the chest B, client might have skin changes, such as dryness and increased sensitivity D, avoid heat exposure A nurse is preparing to administer a unit of packed RBCs to a client who has anemia. Which of the following actions should the nurse plan to take (select all that apply) A. Obtain pre-transfusion temperature B. Prime the IV tubing with lactated Ringer's C. Instruct an assistive personnel to monitor the client during the transfusion D. Verify the client's blood type with a second nurse E. Use a 20 gauge IV needle for venous access - A, D, E -- A, complete assessment prior to transfusion B, prime tubing with a solution that does not cause hemolysis of PRBCs. No LR or 5% dextrose! C, nurse should remain with pt for first 15 minutes of transfusion D, verify identification, blood compatibility, and expiration of product with second nurse E, the nurse should use a large bore needle to transfuse the PRBCs to reduce the risk of cell hemolysis and obstruction of flow A nurse is reviewing the laboratory findings for a client who is dehydrated. Which of the following BUN levels should the nurse expect A. 3.6 mg/dl B. 8 mg/dL C. 18.7 mg/dL D. 26 mg/dL - D Normal range is 10-20, and elevated levels indicates renal disease, dehydration, shock, excessive protein in the diet, sepsis, glucocorticoid use, GI bleeding, or other conditions in which blood is reabsorbed from injured tissues -- A low BUN level can indicate malnutrition, malabsorption, liver disease, fluid overload, or nephrotic syndrome A nurse is reviewing ECG strips for several clients. Which of the following images should the nurse identify as atrial fibrillation (cannot insert pictures, read description) A. multiple irregular and variable waves at the baseline and irregular R to R intervals B. a rate of 140-180/min C. a tachycardia with no identifiable P wave and is determined to originate somewhere other than the ventricles. Rate between 100-280/min D. a P wave for every QRS, rate is 60-100/min - A