ATI TEST B MED SURG QUESTIONS AND ANSWERS

ATI TEST B MED SURG QUESTIONS AND ANSWERS 1. A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the following instructions should the nurse include? a. Flex the foot every hour when awake. b. Place a pillow under the knee when lying in bed. c. Lower the leg when sitting in a chair. d. Ensure the leg is abducted when resting in bed. The nurse should instruct the client to flex the foot every hour to reduce the risk for thromboembolism and promote venous return. 2. 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? a. The chest tube is draining serosanguineous fluid at 65 mL/hr. b. The client tolerates gentle milking of the tubing. c. Bubbling in the water seal chamber has ceased. d. There is tidaling in the water seal chamber. Bubbling in the water seal chamber ceases when the lung re-expands. 3. 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? a. INR 1 b. INR 2.5 c. aPTT 45 seconds d. aPTT 90 seconds 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. 4. 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? a. Clean the wound daily with an antiseptic. b. Use a donut-shaped pillow when sitting in a chair. c. Change position every hour. d. Massage the area two times daily. 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. 5. 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? a. Temperature 37.2° C (99° F) b. Blood pressure 100/70 mm Hg c. Weight loss d. Restlessness 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.