ATI RN ADULT MEDICAL SURGICAL
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EXAM with precise detailed answers
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A |nurse |is |providing |postoperative |teaching |for |a |client |who |had |a |total |knee |arthroplasty. |
Which |of |the |following |instructions |should |the |nurse |include? |- | |correct |answers |Flex |the |foot |
every |hour |when |awake.
Rationale: |The |nurse |should |instruct |the |client |to |flex |the |foot |every |hour |to |reduce |the |risk |
for |thromboembolism |and |promote |venous |return.
A |nurse |is |caring |for |a |client |who |has |a |pneumothorax |and |a |closed-chest |drainage |system. |
Which |of |the |following |findings |is |an |indication |of |lung |re-expansion? |- | |correct |answers |
Bubbling |in |the |water |seal |chamber |has |ceased.
Rationale: |Bubbling |in |the |water |seal |chamber |ceases |when |the |lung |re-expands.
A |nurse |is |reviewing |the |medical |record |of |a |client |who |is |taking |warfarin |for |chronic |atrial |
fibrillation. |Which |of |the |following |values |should |the |nurse |identify |as |a |desired |outcome |for |
this |therapy? |- | |correct |answers |INR |2.5
Rationale: |Clients |receive |warfarin |therapy |to |decrease |the |risk |of |stroke, |myocardial |infarction
|(MI), |or |pulmonary |emboli |(PE) |from |blood |clots. |Since |warfarin |is |an |anticoagulant, |the |
medication |must |be |monitored |to |ensure |the |anticoagulation |is |within |the |therapeutic |range |
and |prevent |hemorrhage |(high |levels |of |anticoagulation) |or |stroke, |MI, |or |PE |(low |levels |of |
anticoagulation). |An |INR |of |2.5 |is |within |the |targeted |therapeutic |range |of |2 |to |3 |for |a |client |
who |has |atrial |fibrillation.
A |home |health |nurse |is |providing |teaching |to |a |client |who |has |a |stage |1 |pressure |injury |on |the
|greater |trochanter |of |his |left |hip. |Which |of |the |following |instructions |should |the |nurse |include
|in |the |teaching? |- | |correct |answers |Change |position |every |hour
Rationale: |Changing |position |every |1 |to |2 |hr |decreases |pressure |on |bony |prominences. |The |
nurse |should |also |instruct |the |client |to |limit |the |angle |of |the |hips |when |in |a |lateral |position |to
|no |more |than |30°. |This |positioning |prevents |direct |pressure |on |the |trochanter.
,A |nurse |is |assessing |a |client |following |the |completion |of |hemodialysis. |Which |of |the |following |
findings |is |the |nurse's |priority |to |report |to |the |provider? |- | |correct |answers |Restlessness
Rationale: |Using |the |urgent |vs. |nonurgent |approach |to |client |care, |the |nurse |should |determine
|that |the |priority |finding |to |report |to |the |provider |is |restlessness, |which |can |be |an |indication |
the |client |is |experiencing |disequilibrium |syndrome. |Disequilibrium |syndrome |is |caused |by |the |
rapid |removal |of |electrolytes |from |the |client's |blood |and |can |lead |to |dysrhythmias |or |seizures.
|Other |manifestations |include |nausea, |vomiting, |fatigue, |and |headache.
A |nurse |is |caring |for |a |client |who |is |8 |hr |postoperative |following |a |total |hip |arthroplasty. |The |
client |is |unable |to |void |on |the |bedpan. |Which |of |the |following |actions |should |the |nurse |take |
first? |- | |correct |answers |Scan |the |bladder |with |a |portable |ultrasound.
Rationale: |The |first |action |the |nurse |should |take |using |the |nursing |process |is |to |assess |the |
client. |Scanning |the |bladder |with |a |portable |ultrasound |device |will |determine |the |amount |of |
urine |in |the |bladder
A |nurse |is |planning |a |health |promotional |presentation |for |a |group |of |African |American |clients |
at |a |community |center. |Which |of |the |following |disorders |presents |the |greatest |risk |to |this |
group |of |clients? |- | |correct |answers |Hypertension
Rationale: |When |using |the |safety/risk |reduction |approach |to |client |care, |the |nurse |should |
determine |that |the |disorder |with |the |greatest |risk |for |this |group |of |clients |is |hypertension. |
The |prevalence |of |hypertension |is |highest |among |African |American |clients, |followed |by |
Caucasian |clients, |and |then |Hispanic |clients.
A |nurse |is |caring |for |a |client |who |has |DKA. |Which |of |the |following |findings |should |indicate |to |
the |nurse |that |the |client's |condition |is |improving? |- | |correct |answers |Glucose |272 |mg/dL
Rationale: |A |glucose |reading |less |than |300 |mg/dL |indicates |improvement |in |the |client's |status.
A |nurse |is |caring |for |a |client |following |extubation |of |an |endotracheal |tube |10 |min. |ago. |Which
|of |the |following |findings |should |the |nurse |report |to |the |provider |immediately? |- | |correct |
answers |Stridor
, Rationale: |Using |the |urgent |vs. |nonurgent |approach |to |client |care, |the |nurse |should |determine
|that |the |priority |finding |is |stridor. |Stridor |can |indicate |a |narrowing |airway |or |possible |
obstruction |caused |by |edema |or |laryngeal |spasms. |The |nurse |should |report |the |finding |
immediately |and |implement |an |intervention.
A |nurse |is |caring |for |a |client |who |had |a |nephrostomy |tube |inserted |112 |hr |ago. |Which |of |the |
following |findings |should |the |nurse |report |to |the |provider? |- | |correct |answers |The |client |
reports |back |pain
Rationale: |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 |admitting |a |client |who |has |active |TB. |Which |of |the |following |types |of |transmission |
precautions |should |the |nurse |initiate? |- | |correct |answers |Airborne
Rationale: |Airborne |precautions |are |required |for |clients |who |have |infections |due |to |micro-
organisms |that |can |remain |suspended |in |air |for |lengthy |periods |of |time, |such |as |tuberculosis, |
measles, |varicella, |and |disseminated |varicella |zoster.
A |nurse |is |planning |care |for |a |client |who |has |a |sealed |radiation |implant |for |cervical |cancer. |
Which |of |the |following |interventions |should |the |nurse |include |in |the |plan |of |care? |- | |correct |
answers |Keep |a |lead-lined |container |in |the |client's |room
Rationale: |The |nurse |should |keep |a |lead-lined |container |and |forceps |in |the |client's |room |in |
case |of |accidental |dislodgement |of |the |implant.
A |nurse |is |assessing |a |client |who |is |postoperative |following |a |thyroidectomy. |Which |of |the |
following |findings |is |the |nurse's |priority? |- | |correct |answers |Temperature |38.9° |C |(102° |F)
Rationale: |When |using |the |urgent |vs. |nonurgent |approach |to |client |care, |the |nurse |should |
determine |that |the |priority |finding |is |an |elevated |temperature. |An |elevated |temperature |is |a |
manifestation |of |excessive |thyroid |hormone |release, |or |thyroid |storm, |due |to |an |increase |in |
metabolic |rate. |The |nurse |should |report |this |finding |immediately |to |the |provider |because |it |
can |lead |to |seizures |and |coma.
| | | | |
EXAM with precise detailed answers
| | | |
A |nurse |is |providing |postoperative |teaching |for |a |client |who |had |a |total |knee |arthroplasty. |
Which |of |the |following |instructions |should |the |nurse |include? |- | |correct |answers |Flex |the |foot |
every |hour |when |awake.
Rationale: |The |nurse |should |instruct |the |client |to |flex |the |foot |every |hour |to |reduce |the |risk |
for |thromboembolism |and |promote |venous |return.
A |nurse |is |caring |for |a |client |who |has |a |pneumothorax |and |a |closed-chest |drainage |system. |
Which |of |the |following |findings |is |an |indication |of |lung |re-expansion? |- | |correct |answers |
Bubbling |in |the |water |seal |chamber |has |ceased.
Rationale: |Bubbling |in |the |water |seal |chamber |ceases |when |the |lung |re-expands.
A |nurse |is |reviewing |the |medical |record |of |a |client |who |is |taking |warfarin |for |chronic |atrial |
fibrillation. |Which |of |the |following |values |should |the |nurse |identify |as |a |desired |outcome |for |
this |therapy? |- | |correct |answers |INR |2.5
Rationale: |Clients |receive |warfarin |therapy |to |decrease |the |risk |of |stroke, |myocardial |infarction
|(MI), |or |pulmonary |emboli |(PE) |from |blood |clots. |Since |warfarin |is |an |anticoagulant, |the |
medication |must |be |monitored |to |ensure |the |anticoagulation |is |within |the |therapeutic |range |
and |prevent |hemorrhage |(high |levels |of |anticoagulation) |or |stroke, |MI, |or |PE |(low |levels |of |
anticoagulation). |An |INR |of |2.5 |is |within |the |targeted |therapeutic |range |of |2 |to |3 |for |a |client |
who |has |atrial |fibrillation.
A |home |health |nurse |is |providing |teaching |to |a |client |who |has |a |stage |1 |pressure |injury |on |the
|greater |trochanter |of |his |left |hip. |Which |of |the |following |instructions |should |the |nurse |include
|in |the |teaching? |- | |correct |answers |Change |position |every |hour
Rationale: |Changing |position |every |1 |to |2 |hr |decreases |pressure |on |bony |prominences. |The |
nurse |should |also |instruct |the |client |to |limit |the |angle |of |the |hips |when |in |a |lateral |position |to
|no |more |than |30°. |This |positioning |prevents |direct |pressure |on |the |trochanter.
,A |nurse |is |assessing |a |client |following |the |completion |of |hemodialysis. |Which |of |the |following |
findings |is |the |nurse's |priority |to |report |to |the |provider? |- | |correct |answers |Restlessness
Rationale: |Using |the |urgent |vs. |nonurgent |approach |to |client |care, |the |nurse |should |determine
|that |the |priority |finding |to |report |to |the |provider |is |restlessness, |which |can |be |an |indication |
the |client |is |experiencing |disequilibrium |syndrome. |Disequilibrium |syndrome |is |caused |by |the |
rapid |removal |of |electrolytes |from |the |client's |blood |and |can |lead |to |dysrhythmias |or |seizures.
|Other |manifestations |include |nausea, |vomiting, |fatigue, |and |headache.
A |nurse |is |caring |for |a |client |who |is |8 |hr |postoperative |following |a |total |hip |arthroplasty. |The |
client |is |unable |to |void |on |the |bedpan. |Which |of |the |following |actions |should |the |nurse |take |
first? |- | |correct |answers |Scan |the |bladder |with |a |portable |ultrasound.
Rationale: |The |first |action |the |nurse |should |take |using |the |nursing |process |is |to |assess |the |
client. |Scanning |the |bladder |with |a |portable |ultrasound |device |will |determine |the |amount |of |
urine |in |the |bladder
A |nurse |is |planning |a |health |promotional |presentation |for |a |group |of |African |American |clients |
at |a |community |center. |Which |of |the |following |disorders |presents |the |greatest |risk |to |this |
group |of |clients? |- | |correct |answers |Hypertension
Rationale: |When |using |the |safety/risk |reduction |approach |to |client |care, |the |nurse |should |
determine |that |the |disorder |with |the |greatest |risk |for |this |group |of |clients |is |hypertension. |
The |prevalence |of |hypertension |is |highest |among |African |American |clients, |followed |by |
Caucasian |clients, |and |then |Hispanic |clients.
A |nurse |is |caring |for |a |client |who |has |DKA. |Which |of |the |following |findings |should |indicate |to |
the |nurse |that |the |client's |condition |is |improving? |- | |correct |answers |Glucose |272 |mg/dL
Rationale: |A |glucose |reading |less |than |300 |mg/dL |indicates |improvement |in |the |client's |status.
A |nurse |is |caring |for |a |client |following |extubation |of |an |endotracheal |tube |10 |min. |ago. |Which
|of |the |following |findings |should |the |nurse |report |to |the |provider |immediately? |- | |correct |
answers |Stridor
, Rationale: |Using |the |urgent |vs. |nonurgent |approach |to |client |care, |the |nurse |should |determine
|that |the |priority |finding |is |stridor. |Stridor |can |indicate |a |narrowing |airway |or |possible |
obstruction |caused |by |edema |or |laryngeal |spasms. |The |nurse |should |report |the |finding |
immediately |and |implement |an |intervention.
A |nurse |is |caring |for |a |client |who |had |a |nephrostomy |tube |inserted |112 |hr |ago. |Which |of |the |
following |findings |should |the |nurse |report |to |the |provider? |- | |correct |answers |The |client |
reports |back |pain
Rationale: |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 |admitting |a |client |who |has |active |TB. |Which |of |the |following |types |of |transmission |
precautions |should |the |nurse |initiate? |- | |correct |answers |Airborne
Rationale: |Airborne |precautions |are |required |for |clients |who |have |infections |due |to |micro-
organisms |that |can |remain |suspended |in |air |for |lengthy |periods |of |time, |such |as |tuberculosis, |
measles, |varicella, |and |disseminated |varicella |zoster.
A |nurse |is |planning |care |for |a |client |who |has |a |sealed |radiation |implant |for |cervical |cancer. |
Which |of |the |following |interventions |should |the |nurse |include |in |the |plan |of |care? |- | |correct |
answers |Keep |a |lead-lined |container |in |the |client's |room
Rationale: |The |nurse |should |keep |a |lead-lined |container |and |forceps |in |the |client's |room |in |
case |of |accidental |dislodgement |of |the |implant.
A |nurse |is |assessing |a |client |who |is |postoperative |following |a |thyroidectomy. |Which |of |the |
following |findings |is |the |nurse's |priority? |- | |correct |answers |Temperature |38.9° |C |(102° |F)
Rationale: |When |using |the |urgent |vs. |nonurgent |approach |to |client |care, |the |nurse |should |
determine |that |the |priority |finding |is |an |elevated |temperature. |An |elevated |temperature |is |a |
manifestation |of |excessive |thyroid |hormone |release, |or |thyroid |storm, |due |to |an |increase |in |
metabolic |rate. |The |nurse |should |report |this |finding |immediately |to |the |provider |because |it |
can |lead |to |seizures |and |coma.
