ATI NCLEX Medical Surgical Assessment 1 Newest Updated 2024
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 - 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. 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 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
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 - 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. 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 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
