NGN Exam Retake 2 ATI RN Medical Surgical Med Surg A with rationales

NGN Exam Retake 2 ATI RN Medical Surgical Med Surg A with rationales A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which of the following findings indicates that the client is experiencing increased intracranial pressure (ICP)? (Select all that apply.) A. Flat jugular veins B. A Glasgow Coma Scale score of 15 C. Sleepiness exhibited by the client D. Widening pulse pressure E. Decerebrate posturing - CORRECT ANSWER C, D, E Flat jugular veins is incorrect. With increased ICP, the jugular veins are typically distended. A Glasgow Coma Scale score of 15 is incorrect. A Glasgow Coma Scale score of 15 indicates neurological functioning within the expected reference range for eye opening, motor, and verbal response. Sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the client from sleep is an indication of increased ICP. Widening pulse pressure is correct. A widening pulse pressure (increase in systolic with concurrent decrease in diastolic blood pressure) is an indication of increased ICP. Decerebrate posturing is correct. Both decerebrate and decorticate posturing indicate increased ICP. A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. Which of the following prescribed medications should the nurse instruct the client to withhold for 48 hr prior to cardioversion? A. Enoxaparin B. Metformin C. Diazepam D. Digoxin - CORRECT ANSWER D. Digoxin Cardiac glycosides, such as digoxin, are withheld prior to cardioversion. These medications can increase ventricular irritability and put the client at risk for ventricular fibrillation after the synchronized countershock of cardioversion. AA A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurse's priority? A. Anorexia B. Abdominal pain radiating to the right shoulder C. Tachycardia D. Rebound abdominal tenderness - CORRECT ANSWER C. Tachycardia The nurse should wear a lead apron when providing direct care to provide protection from the radiation source and not turn their back toward the client, because the apron only shields the front of the body. The nurse should also wear a dosimeter film badge to measure radiation exposure. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take? A. Remain with the client for the first 15 min of the infusion B. Prime the blood administration IV tubing with lactated Ringer's solution C. Verify the client's identity by using the client's room number prior to starting the transfusion D. Infuse the unit of packed RBCs within 8 hr - CORRECT ANSWER A. Remain with the client for the first 15 min of the infusion The nurse should remain with the client for the first 15 to 30 min of the infusion because hemolytic reactions usually occur during the infusion of the first 50 mL of blood. A nurse is caring for a client who presents to a clinic for a 1-week follow-up visit after hospitalization for heart failure. Based on the information in the client's chart, which of the following findings should the nurse report to the provider? A. Potassium 4.1 mEq/L B. Heart rate 55/min C. SaO2 92% D. Weight 67.1 kg (148 lb) - CORRECT ANSWER B. Heart rate 55/min The client's heart rate of 55/min is a decrease from the client's baseline of 74/min, and it can indicate the development of digoxin toxicity. The nurse should report this finding to the provider. A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following assessment findings should the nurse expect? A. Positive Trousseau's sign