ATI Medical SurgicalAssessment E
j j j j
Ajnursejisjplanningjcarejforjajclientjwhojisjreceivingjmechanicaljventilation.jWhichjofjthejfollo
wingjactionsjshouldjthejnursejincludejinjthejplan
A.jProvidejthej clientjwithj ajmeansjofjcommunicationjB.j
Maintainjthejheadjofjthejclient'sjbedjinjajflatjpositionjC.jSuc
tionjthejclient'sjendotrachealjtubejeveryj4jhr
D.jPerformjoraljhygienejforjthejclientjeveryj8jhrj-jA
Usejelectronicjtabletjcomputer,jprogrammablejspeechjgeneratingjdevice,jalphabetjboard,jpe
nciljandjpaper,jetc
--
B,jkeepjheadjofjbedjhigherjthanj30jdegreesjtojpreventjaspirationjandjventilatorjassociatedjpneu
monia.jTurnjthejclientjqj2hrjtojpreventjcomplicationsjrelatedjtojimmobility
C,jassessjthejneedjtojsuctionjqj2-
4jhr,jbutjnotjperformjroutinejsuctioning.jBasejthejneedjforjsuctioningjonjassessments,jnotjajsched
ule.jUnnecessaryjsuctioningjcanjcausejbroncojspasmsjandjinjuryjtrachealjmucosa
D,joraljhygienejshouldjbejperformedjqj2jhrjtojdecreasejthejriskjofjventilatorjassociatedjpneu
monia
AjnursejisjcaringjforjajclientjwhojisjreceivingjIVjfluidjreplacementjtherapyjforjdehydration.jWhi
chjofjthejfollowingjlaboratoryjresultsjindicatesjeffectivenessjofjthejtreatment
A.jSodiumj165jmEq/LjB.j
Potassiumj5.2jmEq/L
C.jUrinejspecificjgravityj1.020j
D.jHctj62%j-jC
Withinjthejexpectedjrangejofj1.005-1.030
--
A,jsodiumjrangejisj136-145
B,jpotassiumjrangejisj3.5-5
D,jHctjrangejisj37%-52%
Ajnursejisjmonitoringjthejlaboratoryjfindingsjforjajclientjwhojisjpostoperativejfollowingjajtotaljh
ipjarthroplastyj6jhrjago.jWhichjofjthejfollowingjvaluesjindicatesjthatjthejclientjhasjanjincreasedjri
skjforjbleeding
A.jPTj11.5jsecondsj
B.jaPTTj35jsecondsj
C.jPlateletsj80,000
D.jRBCj4.0jmillionj-jC
,plateletjrangejisj150,000-400,000
--
A,jPTjrangejisj11-12.5
B,jaPTTjrangejisj30-40jseconds
D,jRBCjrangejisj4.2-
6.1jmillion.jAjlowjRBCjcanjindicatejthatjbleedingjhasjoccurred,jbutjitjdoesjnotjindicatejthatjthejc
lientjisjatjriskjforjbleeding
Ajnursejisjadmittingjajclientjwhojhasjajcervicaljspinaljcordjinjuryjfollowingjajmotorjvehiclejcrash
.jWhichjofjthejfollowingjinterventionsjisjthejnurse'sjpriorityjwhilejcaringjforjthisjclient
A. Changejthejclient'sjpositionjeveryj2jhours
B. Padjpressurejpointsjatjthejedgesjofjthejclient'sjcervicaljcollarjC.j
Palpatejthejclient'sjabdomenjforjbladderjdistention
D.jAssistjthejclientjwithjquadjcoughingj-jD
Thejgreatestjriskjtojajclientjwhojhasjajcervicaljspinaljcordjinjuryjisjanjobstructedjairway;jthejpriori
tyjisjtojensurejthejclientjcanjclearjtheirjairway.jApplyjabdominaljpressurejasjthejclientjcoughsj(qu
adjcoughing)
Ajnursejisjcaringjforjajclientjwhojisjreceivingjajbloodjtransfusion.jWhichjofjthejfollowingjfindin
gsjindicatesjthatjthejclientjisjexperiencingjtransfusion-associatedjcirculatoryjoverload
A. Nasuea
B. Hypothermiaj
C.jDyspnea
D.jBradycardiaj-jC
Dyspneajisjanjindicationjofjpossiblejtransfusionjassociatedjcirculatoryjoverload,jleadingjtojhyperte
nsion,jboundingjpulses,jandjconfusion.jDyspneajcanjalsojindicatejtransfusionjrelatedjacutejlungjinj
uryjtojanjanaphylacticjresponse,jwhichjalsojcausesjwheezing,jchestjtightness,jcyanosis,jandjlowjBP
--
A,jnauseajcanjindicatejanjacutejhemolyticjtransfusionjreaction
B,jtransfusionjreactionsjincludejacutejhemolytic,jfebrile,jmildjallergic,jandjanaphylactic
D,jbradycardiajisjnotjanjindication
Ajnursejisjassessingjajclientjwhojhasjlungjcancerjandjisjundergoingjradiationjtherapyjtojthejchest
.jWhichjofjthejfollowingjindicatesjanjadversejeffectjofjthejtherapy
A. Hairjlossjonjthejscalp
B. Sweatingjatjthejtreatmentjsitej
C.jAlteredjtastejsensations
D.jIntolerancejtojcoldj-jC
Alteredjtastejisjajresultjofjthejreleasejofjmetabolitesjbyjdeadjcells
--
, A,jclientjmayjhavejhairjlossjatjthejtreatmentjsitejonjthejchest
B,jclientjmightjhavejskinjchanges,jsuchjasjdrynessjandjincreasedjsensitivity
D,javoidjheatjexposure
AjnursejisjpreparingjtojadministerjajunitjofjpackedjRBCsjtojajclientjwhojhasjanemia.jWhichjofjthej
followingjactionsjshouldjthejnursejplanjtojtakej(selectjalljthatjapply)
A. Obtainjpre-transfusionjtemperature
B. PrimejthejIVjtubingjwithjlactatedjRinger's
C. InstructjanjassistivejpersonneljtojmonitorjthejclientjduringjthejtransfusionjD.j
Verifyjthejclient'sjbloodjtypejwithjajsecondjnurse
E.jUsejaj20jgaugejIVjneedlejforjvenousjaccessj-jA,jD,jE
--
A,jcompletejassessmentjpriorjtojtransfusion
B,jprimejtubingjwithjajsolutionjthatjdoesjnotjcausejhemolysisjofjPRBCs.jNojLRjorj5%jdextr
ose!
C,jnursejshouldjremainjwithjptjforjfirstj15jminutesjofjtransfusion
D,jverifyjidentification,jbloodjcompatibility,jandjexpirationjofjproductjwithjsecondjnurse
E,jthejnursejshouldjusejajlargejborejneedlejtojtransfusejthejPRBCsjtojreducejthejriskjofjcelljhemol
ysisjandjobstructionjofjflow
Ajnursejisjreviewingjthejlaboratoryjfindingsjforjajclientjwhojisjdehydrated.jWhichjofjthejfollo
wingjBUNjlevelsjshouldjthejnursejexpect
A.j3.6jmg/dlj
B.j8jmg/dL
C.j18.7jmg/dLjD.
j26jmg/dLj-jD
Normaljrangejisj10-
20,jandjelevatedjlevelsjindicatesjrenaljdisease,jdehydration,jshock,jexcessivejproteinjinjthejdie
t,jsepsis,jglucocorticoidjuse,jGIjbleeding,jorjotherjconditionsjinjwhichjbloodjisjreabsorbedjfro
mjinjuredjtissues
--
AjlowjBUNjleveljcanjindicatejmalnutrition,jmalabsorption,jliverjdisease,jfluidjoverload,jorjnep
hroticjsyndrome
AjnursejisjreviewingjECGjstripsjforjseveraljclients.jWhichjofjthejfollowingjimagesjshouldjthejn
ursejidentifyjasjatrialjfibrillation
(cannotjinsertjpictures,jreadjdescription)
A. multiplejirregularjandjvariablejwavesjatjthejbaselinejandjirregularjRjtojRjintervals
j j j j
Ajnursejisjplanningjcarejforjajclientjwhojisjreceivingjmechanicaljventilation.jWhichjofjthejfollo
wingjactionsjshouldjthejnursejincludejinjthejplan
A.jProvidejthej clientjwithj ajmeansjofjcommunicationjB.j
Maintainjthejheadjofjthejclient'sjbedjinjajflatjpositionjC.jSuc
tionjthejclient'sjendotrachealjtubejeveryj4jhr
D.jPerformjoraljhygienejforjthejclientjeveryj8jhrj-jA
Usejelectronicjtabletjcomputer,jprogrammablejspeechjgeneratingjdevice,jalphabetjboard,jpe
nciljandjpaper,jetc
--
B,jkeepjheadjofjbedjhigherjthanj30jdegreesjtojpreventjaspirationjandjventilatorjassociatedjpneu
monia.jTurnjthejclientjqj2hrjtojpreventjcomplicationsjrelatedjtojimmobility
C,jassessjthejneedjtojsuctionjqj2-
4jhr,jbutjnotjperformjroutinejsuctioning.jBasejthejneedjforjsuctioningjonjassessments,jnotjajsched
ule.jUnnecessaryjsuctioningjcanjcausejbroncojspasmsjandjinjuryjtrachealjmucosa
D,joraljhygienejshouldjbejperformedjqj2jhrjtojdecreasejthejriskjofjventilatorjassociatedjpneu
monia
AjnursejisjcaringjforjajclientjwhojisjreceivingjIVjfluidjreplacementjtherapyjforjdehydration.jWhi
chjofjthejfollowingjlaboratoryjresultsjindicatesjeffectivenessjofjthejtreatment
A.jSodiumj165jmEq/LjB.j
Potassiumj5.2jmEq/L
C.jUrinejspecificjgravityj1.020j
D.jHctj62%j-jC
Withinjthejexpectedjrangejofj1.005-1.030
--
A,jsodiumjrangejisj136-145
B,jpotassiumjrangejisj3.5-5
D,jHctjrangejisj37%-52%
Ajnursejisjmonitoringjthejlaboratoryjfindingsjforjajclientjwhojisjpostoperativejfollowingjajtotaljh
ipjarthroplastyj6jhrjago.jWhichjofjthejfollowingjvaluesjindicatesjthatjthejclientjhasjanjincreasedjri
skjforjbleeding
A.jPTj11.5jsecondsj
B.jaPTTj35jsecondsj
C.jPlateletsj80,000
D.jRBCj4.0jmillionj-jC
,plateletjrangejisj150,000-400,000
--
A,jPTjrangejisj11-12.5
B,jaPTTjrangejisj30-40jseconds
D,jRBCjrangejisj4.2-
6.1jmillion.jAjlowjRBCjcanjindicatejthatjbleedingjhasjoccurred,jbutjitjdoesjnotjindicatejthatjthejc
lientjisjatjriskjforjbleeding
Ajnursejisjadmittingjajclientjwhojhasjajcervicaljspinaljcordjinjuryjfollowingjajmotorjvehiclejcrash
.jWhichjofjthejfollowingjinterventionsjisjthejnurse'sjpriorityjwhilejcaringjforjthisjclient
A. Changejthejclient'sjpositionjeveryj2jhours
B. Padjpressurejpointsjatjthejedgesjofjthejclient'sjcervicaljcollarjC.j
Palpatejthejclient'sjabdomenjforjbladderjdistention
D.jAssistjthejclientjwithjquadjcoughingj-jD
Thejgreatestjriskjtojajclientjwhojhasjajcervicaljspinaljcordjinjuryjisjanjobstructedjairway;jthejpriori
tyjisjtojensurejthejclientjcanjclearjtheirjairway.jApplyjabdominaljpressurejasjthejclientjcoughsj(qu
adjcoughing)
Ajnursejisjcaringjforjajclientjwhojisjreceivingjajbloodjtransfusion.jWhichjofjthejfollowingjfindin
gsjindicatesjthatjthejclientjisjexperiencingjtransfusion-associatedjcirculatoryjoverload
A. Nasuea
B. Hypothermiaj
C.jDyspnea
D.jBradycardiaj-jC
Dyspneajisjanjindicationjofjpossiblejtransfusionjassociatedjcirculatoryjoverload,jleadingjtojhyperte
nsion,jboundingjpulses,jandjconfusion.jDyspneajcanjalsojindicatejtransfusionjrelatedjacutejlungjinj
uryjtojanjanaphylacticjresponse,jwhichjalsojcausesjwheezing,jchestjtightness,jcyanosis,jandjlowjBP
--
A,jnauseajcanjindicatejanjacutejhemolyticjtransfusionjreaction
B,jtransfusionjreactionsjincludejacutejhemolytic,jfebrile,jmildjallergic,jandjanaphylactic
D,jbradycardiajisjnotjanjindication
Ajnursejisjassessingjajclientjwhojhasjlungjcancerjandjisjundergoingjradiationjtherapyjtojthejchest
.jWhichjofjthejfollowingjindicatesjanjadversejeffectjofjthejtherapy
A. Hairjlossjonjthejscalp
B. Sweatingjatjthejtreatmentjsitej
C.jAlteredjtastejsensations
D.jIntolerancejtojcoldj-jC
Alteredjtastejisjajresultjofjthejreleasejofjmetabolitesjbyjdeadjcells
--
, A,jclientjmayjhavejhairjlossjatjthejtreatmentjsitejonjthejchest
B,jclientjmightjhavejskinjchanges,jsuchjasjdrynessjandjincreasedjsensitivity
D,javoidjheatjexposure
AjnursejisjpreparingjtojadministerjajunitjofjpackedjRBCsjtojajclientjwhojhasjanemia.jWhichjofjthej
followingjactionsjshouldjthejnursejplanjtojtakej(selectjalljthatjapply)
A. Obtainjpre-transfusionjtemperature
B. PrimejthejIVjtubingjwithjlactatedjRinger's
C. InstructjanjassistivejpersonneljtojmonitorjthejclientjduringjthejtransfusionjD.j
Verifyjthejclient'sjbloodjtypejwithjajsecondjnurse
E.jUsejaj20jgaugejIVjneedlejforjvenousjaccessj-jA,jD,jE
--
A,jcompletejassessmentjpriorjtojtransfusion
B,jprimejtubingjwithjajsolutionjthatjdoesjnotjcausejhemolysisjofjPRBCs.jNojLRjorj5%jdextr
ose!
C,jnursejshouldjremainjwithjptjforjfirstj15jminutesjofjtransfusion
D,jverifyjidentification,jbloodjcompatibility,jandjexpirationjofjproductjwithjsecondjnurse
E,jthejnursejshouldjusejajlargejborejneedlejtojtransfusejthejPRBCsjtojreducejthejriskjofjcelljhemol
ysisjandjobstructionjofjflow
Ajnursejisjreviewingjthejlaboratoryjfindingsjforjajclientjwhojisjdehydrated.jWhichjofjthejfollo
wingjBUNjlevelsjshouldjthejnursejexpect
A.j3.6jmg/dlj
B.j8jmg/dL
C.j18.7jmg/dLjD.
j26jmg/dLj-jD
Normaljrangejisj10-
20,jandjelevatedjlevelsjindicatesjrenaljdisease,jdehydration,jshock,jexcessivejproteinjinjthejdie
t,jsepsis,jglucocorticoidjuse,jGIjbleeding,jorjotherjconditionsjinjwhichjbloodjisjreabsorbedjfro
mjinjuredjtissues
--
AjlowjBUNjleveljcanjindicatejmalnutrition,jmalabsorption,jliverjdisease,jfluidjoverload,jorjnep
hroticjsyndrome
AjnursejisjreviewingjECGjstripsjforjseveraljclients.jWhichjofjthejfollowingjimagesjshouldjthejn
ursejidentifyjasjatrialjfibrillation
(cannotjinsertjpictures,jreadjdescription)
A. multiplejirregularjandjvariablejwavesjatjthejbaselinejandjirregularjRjtojRjintervals