ATI NCLEX Medical Surgical Assessment/ Complete Exam With 100% Correct 60 Questions and Answers 2024 Guide

ATI NCLEX Medical Surgical Assessment/ Complete Exam With 100% Correct 60 Questions and Answers 2024 Guide A nurse in an emergency department is monitoring a client who reports angina. Which of the following findings should indicate to the nurse that the client might have experienced a myocardial infarction (MI) A. Increased troponin B. Decreased creatinine kinase MB C. Cholesterol 300 mg/dL D. C- reactive protein 1.2 mg/dL (Answer: - A Troponin is a myocardial muscle protein released into the blood stream as a result of injury to the heart muscle. Troponin levels increase within 2-3 hr following an MI -- B, creatinine kinase MB elevates when there is injury to brain tissue, myocardial muscle, or skeletal muscle C, elevated cholesterol increases the risk for cardiovascular disease, but does not diagnose an MI D, this is within the expected reference range A nurse is preparing to obtain blood cultures from a client's central venous catheter (CVC). Which of the following actions should the nurse take when accessing the catheter A. Flush the lumen with heparin solution before each use B. Aspirate for blood return prior to each use C. Perform a 5 second scrub to the catheter hub before accessing the catheter D. Apply firm pressure to the syringe plunger when flushing the lumen (Answer: - B -- A, flush the lumen of any CVC with 0.9% sodium chloride. The nurse can flush an implanted port with 5mL heparin 10 units / mL to prevent clots C, 15 second scrub D, apply slow, even pressure to the syringe plunger to flush the lumen, and immediately stop if there is resistance. Use a 10mL syringe when flushing central catheters A nurse on a medical surgical unit has received shift report for a group of clients. Which of the following interventions should the nurse plan to complete first A. Perform a dressing change on a client who is 24 hr postoperative following abdominal surgery and has sanguineous drainage on the dressing B. Replace an infiltrated IV for a client who has pneumonia and has scheduled IV antibiotics due in 30 minutes C. administer a prescribed opioid pain medication to a client who is reporting back pain as a 5 on a numeric pain scale of 0 to 10 D. Assess a client who is 4hr postoperative following thoracic surgery and has a respiratory rate of 7/min (Answer: - D Using the ABC approach, this is the priority. A RR of 7 indicates hypoventilation and can indicate respiratory failure or shock, especially in pt who is postop. A nurse on a medical unit is planning care for a client who has COPD. Which of the following actions should the nurse include in the plan A. Suction the client's airway every 4 hours B. Limit the client's fluid intake to control secretions C. Provide the client with a high protein diet D. Administer the client's bronchodilator following each meal (Answer: - C COPD needs a diet high in protein and calories. They should eat freuqent, small meals and should avoid drinking fluids prior to or during meals -- A, do not suction COPD on a routine basis, only suction as necessary to clear secretions and maintain a patent airway B, encourage the intake of fluids at least 2L/day to help thin secretions D, administer bronchodilator 30 min prior to meals to reduce the risk of bronchospasm