ATI Medical Surgical NCLEX Assessment 1 Latest Updated 2024
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 - ANSWER-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 - ANSWER-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 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 - ANSWER-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% - ANSWER-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 - ANSWER-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 the client's cervical collar
C. Palpate the client's abdomen for bladder distention
D. Assist the client with quad coughing - ANSWER-D
The greatest risk to a client who has a cervical spinal cord injury is an obstructed airway; the priority is to
ensure the client can clear their airway. Apply abdominal pressure as the client coughs (quad coughing)
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 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 - ANSWER-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 - ANSWER-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 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 - ANSWER-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% - ANSWER-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 - ANSWER-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 the client's cervical collar
C. Palpate the client's abdomen for bladder distention
D. Assist the client with quad coughing - ANSWER-D
The greatest risk to a client who has a cervical spinal cord injury is an obstructed airway; the priority is to
ensure the client can clear their airway. Apply abdominal pressure as the client coughs (quad coughing)
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
