ATI Med-Surg Set 2023 Review
A nurse is administering packed red blood cells to a client. What should the nurse do if a transfusion
reaction is suspected? - answerStop the infusion.
A nurse is caring for a client with skeletal traction following a fracture. How and when should skeletal
pin care be provided? - answerOne cotton swab with chlorhexidine is designated for each pin for pin
care to be done once a shift.
A nurse is providing dietary teaching to a client newly diagnosed with constipation-predominant irritable
bowel syndrome. List two (2) teaching points the should share with the client about dietary practices. -
answerEat foods high in fiber
Increase fluids
Late Cushing's Triad manifestation - answerSevere hypertension with widening of pulse pressure and
bradycardia
Identifying Basal cell cancer - answersmall, waxy nodule with superficial blood vessels, well-defined
borders
Teaching post Bronchoscopy - answerassess LOC, cough and gag reflex, and ability to swallow before
consuming oral intake
Teaching how to prevent transmission of HIV - answertake antiretroviral medications to inhibit DNA
synthesis and Viral replication
ABGs
Determine imbalance - answer
, Blood compatibility:
Nursing Actions for Hemolytic transfusion reaction - answerRemove the blood tubing from the IV access
site. Initiate an infusion of 0.9% of sodium chloride using new tubing. Monitor VS and fluid status. Send
the blood bag and administrating set to the lab for testing.
Priority intervention for Complication of Central Venous Catheter - answer1) look for safety risk; what is
the risk for patient and how significant is the risk? 2)
Teaching about levothyroxine (overdose manifestations) - answerovermedication can result
thyrotoxicosis (anxiety, tachycardia, heat intolerance, fever, diaphoresis, weight loss, palpatations, chest
pain, abd pain, nervousness, tremors
Care of a perpherially inserted central catheter infusion system - answeraccess site for redness, swelling,
drainage, tenderness, and condition of the dressing.
Evaluating effectiveness of fluid replacement - answerhematocrit, increase hypovolemia
Caring for pt with peritoneal dialysis: - answermonitor for signs of infection (bloody, cloudy or frothy
dialysate return, monitor for complications: respiratory distress, abd pain, insufficient flow, and
discolored outflow
Identifying reaction to radiation therapy - answerskin blanching, erthyma, sloughing, desquamous,
hemorrhage
Priority action following surgical repair of abdominal aortic aneurysm - answerLook for risk, monitor
incision site, report infection
Manifestations of diverticular Disease - answeracute onset of abdominal pain often in left lower
quadrant
A nurse is administering packed red blood cells to a client. What should the nurse do if a transfusion
reaction is suspected? - answerStop the infusion.
A nurse is caring for a client with skeletal traction following a fracture. How and when should skeletal
pin care be provided? - answerOne cotton swab with chlorhexidine is designated for each pin for pin
care to be done once a shift.
A nurse is providing dietary teaching to a client newly diagnosed with constipation-predominant irritable
bowel syndrome. List two (2) teaching points the should share with the client about dietary practices. -
answerEat foods high in fiber
Increase fluids
Late Cushing's Triad manifestation - answerSevere hypertension with widening of pulse pressure and
bradycardia
Identifying Basal cell cancer - answersmall, waxy nodule with superficial blood vessels, well-defined
borders
Teaching post Bronchoscopy - answerassess LOC, cough and gag reflex, and ability to swallow before
consuming oral intake
Teaching how to prevent transmission of HIV - answertake antiretroviral medications to inhibit DNA
synthesis and Viral replication
ABGs
Determine imbalance - answer
, Blood compatibility:
Nursing Actions for Hemolytic transfusion reaction - answerRemove the blood tubing from the IV access
site. Initiate an infusion of 0.9% of sodium chloride using new tubing. Monitor VS and fluid status. Send
the blood bag and administrating set to the lab for testing.
Priority intervention for Complication of Central Venous Catheter - answer1) look for safety risk; what is
the risk for patient and how significant is the risk? 2)
Teaching about levothyroxine (overdose manifestations) - answerovermedication can result
thyrotoxicosis (anxiety, tachycardia, heat intolerance, fever, diaphoresis, weight loss, palpatations, chest
pain, abd pain, nervousness, tremors
Care of a perpherially inserted central catheter infusion system - answeraccess site for redness, swelling,
drainage, tenderness, and condition of the dressing.
Evaluating effectiveness of fluid replacement - answerhematocrit, increase hypovolemia
Caring for pt with peritoneal dialysis: - answermonitor for signs of infection (bloody, cloudy or frothy
dialysate return, monitor for complications: respiratory distress, abd pain, insufficient flow, and
discolored outflow
Identifying reaction to radiation therapy - answerskin blanching, erthyma, sloughing, desquamous,
hemorrhage
Priority action following surgical repair of abdominal aortic aneurysm - answerLook for risk, monitor
incision site, report infection
Manifestations of diverticular Disease - answeracute onset of abdominal pain often in left lower
quadrant
