REVIEWED ATI RN ADULT (NGN) MEDICAL SURGICAL PROCTORED RETAKE EXAM 2019 WITH GUARANTEED DISTINCTION UPDATED 2023

REVIEWED ATI RN ADULT (NGN) MEDICAL SURGICAL PROCTORED RETAKE EXAM 2019 WITH GUARANTEED DISTINCTION UPDATED 2023  A nurse in a provider’s office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client’s patellar reflex? One with the knee.  A nurse is assessing an older adult client’s risk for fall. Which of the following assessments should the nurse use to identify the client’s safety needs? (Select all that apply.) a. Lacrimal apparatus If clients have impairment in the ability to produce tears, it should not affect their fall risk. The nurse tests this by palpating the tear duct at the lower eyelid to see if any tears emerge. b. Pupil clarity Cloudy pupils mean that the client has cataracts. This makes vision cloudy and creates halos around lights, which can increase the risk for falls because clients cannot see items in their path clearly. c. Appearance of bulbar conjunctivae The nurse should examine the bulbar conjunctivae by gently retracting the lower and upper lids to evaluate color and texture and assess for the presence of infection. However, the condition of the conjunctivae will not impede the client’s safety. d. Visual fields The nurse should use a finger to test the client’s peripheral vison by moving the finger out of range and then back into the visual field to determine when the client sees the finger. Clients who have a visual field impairment are at an increased risk for falls because they might not see objects outside of their central vision and trip over them or bump into them and fall. e. Visual acuity The nurse should use a Snellen chart to assess distance vision and a handheld card to assess near vision. Client who wear eyeglasses should wear them during the assessments. Clients who have impaired visual acuity are at an increased risk for falls because they might not see objects in their path and trip over them or bump into them and fall.  A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse’s priority? a. Request that a respiratory therapist discuss the technique for incentive spirometry with the client. The nurse can request that another team member discuss the use of the incentive spirometer with the client to encourage the client to use it; however, this is not the priority action for the nurse to take. b. Determine the reasons why the client is refusing to use the incentive spirometer. The first action the nurse should take when using the nursing process is to assess the client; therefore, the priority action for the nurse to take is to determine why the client is refusing the treatment. c. Document the client’s refusal to participate in health restorative activities. If other interventions to promote the client’s use of the incentive spirometer are unsuccessful, the nurse must document the client’s refusal; however, this is not the priority action for the nurse to take. d. Administer a pain medication to the client. Pain or incisional complications might make the client refuse spirometry; however, administering medication is not the priority action for the nurse to take.  A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? a. Bladder distention Urinary retention, which causes bladder distention, is a common complication of bed rest due to a loss of muscle tone in the bladder and detrusor muscles. b. Decreased blood pressure A client who requires bed rest can develop postural hypotension, which is a drop in blood pressure when the client moved from a lying to a sitting position. The nurse should also assess the client for an increase in pulse rate and dizziness. c. Calf swelling Swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility. d. Diminished bowel sounds A decrease in bowel sounds reflects slowed peristalsis. Constipation is a common complication