Capstone ATI NCLEX Medical Surgical Assessment Latest 100% Correct Questions and Answers +Rationale (Complete Exam)

Capstone ATI NCLEX Medical Surgical Assessment Latest 100% Correct Questions and Answers +Rationale (Complete Exam) A nurse is admitting a client who has a cervical spinal cord injury following a motor vehicle crash. Which of the following interventions is the nurse's priority while caring for this client? A. Change the client's position every 2 hours B. Pad pressure points at the edges of the client's cervical collar C. Palpate the client's abdomen for bladder distention D. Assist the client with quad coughing [Correct Ans: - D Assist the client with quad coughing The greatest risk to a client who has a cervical spinal cord injury is an obstructed airway; the priority is to ensure the client can clear their airway. Apply abdominal pressure as the client coughs (quad coughing) A nurse is caring for a client who is receiving a blood transfusion. Which of the following findings indicates that the client is experiencing transfusion-associated circulatory overload A. Nasuea B. Hypothermia C. Dyspnea D. Bradycardia [Correct Ans: - C Dyspnea Dyspnea is an indication of possible transfusion associated circulatory overload, leading to hypertension, bounding pulses, and confusion. Dyspnea can also indicate transfusion related acute lung injury to an anaphylactic response, which also causes wheezing, chest tightness, cyanosis, and low BP A nurse is assessing a client who has lung cancer and is undergoing radiation therapy to the chest. Which of the following indicates an adverse effect of the therapy A. Hair loss on the scalp B. Sweating at the treatment site C. Altered taste sensations D. Intolerance to cold [Correct Ans: - C Altered taste sensations Altered taste is a result of the release of metabolites by dead cells