ATI NCLEX MEDICAL SURGICAL ASSESSMENT 1
A nurse is planning care for a client who is receiving mechanical ventilation. Which of
the following actions should the nurse include in the plan
A. Provide the client with a means of communication
B. Maintain the head of the client's bed in a flat position
C. Suction the client's endotracheal tube every 4 hr
D. Perform oral hygiene for the client every 8 hr - Answers -A
Use electronic tablet computer, programmable speech generating device, alphabet
board, pencil and paper, etc
--
B, keep head of bed higher than 30 degrees to prevent aspiration and ventilator
associated pneumonia. Turn the client q 2hr to prevent complications related to
immobility
C, assess the need to suction q 2-4 hr, but not perform routine suctioning. Base the
need for suctioning on assessments, not a schedule. Unnecessary suctioning can
cause bronco spasms and injury tracheal mucosa
D, oral hygiene should be performed q 2 hr to decrease the risk of ventilator associated
pneumonia
A nurse is reviewing ECG strips for several clients. Which of the following images
should the nurse identify as atrial fibrillation
(cannot insert pictures, read description)
A. multiple irregular and variable waves at the baseline and irregular R to R intervals
B. a rate of 140-180/min
C. a tachycardia with no identifiable P wave and is determined to originate somewhere
other than the ventricles. Rate between 100-280/min
D. a P wave for every QRS, rate is 60-100/min - Answers -A
--
B, Vtach
C, SVT
D, normal sinus
,A nurse is preparing to admit a client who has a new tracheostomy from the operating
room. Which of the following items is the priority for the nurse to have available in the
client's room upon admission
A. Obturator
B. Hydrogen peroxide
C. Sterile gloves
D. Inner cannula - Answers -A
The obturator can be inserted in the stoma in the even of dislodgment or decannulation
to maintain an airway until a new trach tube can be placed. For the first 72 hr following
the insertion of a trach, dislodgement or decannulation is considered an emergency
--
B, used for trach care, but not priority
C, sterile gloves for suctioning or for dressing change, but not priority
D, inner cannula in case it needs to be replaced, but not priority
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 - Answers -C
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, nausea can indicate an acute hemolytic transfusion reaction
B, transfusion reactions include acute hemolytic, febrile, mild allergic, and anaphylactic
D, bradycardia is not an indication
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 - Answers -C
, Altered taste is a result of the release of metabolites by dead cells
--
A, client may have hair loss at the treatment site on the chest
B, client might have skin changes, such as dryness and increased sensitivity
D, avoid heat exposure
A nurse is preparing to administer a unit of packed RBCs to a client who has anemia.
Which of the following actions should the nurse plan to take (select all that apply)
A. Obtain pre-transfusion temperature
B. Prime the IV tubing with lactated Ringer's
C. Instruct an assistive personnel to monitor the client during the transfusion
D. Verify the client's blood type with a second nurse
E. Use a 20 gauge IV needle for venous access - Answers -A, D, E
--
A, complete assessment prior to transfusion
B, prime tubing with a solution that does not cause hemolysis of PRBCs. No LR or 5%
dextrose!
C, nurse should remain with pt for first 15 minutes of transfusion
D, verify identification, blood compatibility, and expiration of product with second nurse
E, the nurse should use a large bore needle to transfuse the PRBCs to reduce the risk
of cell hemolysis and obstruction of flow
A nurse is reviewing the laboratory findings for a client who is dehydrated. Which of the
following BUN levels should the nurse expect
A. 3.6 mg/dl
B. 8 mg/dL
C. 18.7 mg/dL
D. 26 mg/dL - Answers -D
Normal range is 10-20, and elevated levels indicates renal disease, dehydration, shock,
excessive protein in the diet, sepsis, glucocorticoid use, GI bleeding, or other conditions
in which blood is reabsorbed from injured tissues
--
A low BUN level can indicate malnutrition, malabsorption, liver disease, fluid overload,
or nephrotic syndrome
A nurse is planning care for a client who is receiving mechanical ventilation. Which of
the following actions should the nurse include in the plan
A. Provide the client with a means of communication
B. Maintain the head of the client's bed in a flat position
C. Suction the client's endotracheal tube every 4 hr
D. Perform oral hygiene for the client every 8 hr - Answers -A
Use electronic tablet computer, programmable speech generating device, alphabet
board, pencil and paper, etc
--
B, keep head of bed higher than 30 degrees to prevent aspiration and ventilator
associated pneumonia. Turn the client q 2hr to prevent complications related to
immobility
C, assess the need to suction q 2-4 hr, but not perform routine suctioning. Base the
need for suctioning on assessments, not a schedule. Unnecessary suctioning can
cause bronco spasms and injury tracheal mucosa
D, oral hygiene should be performed q 2 hr to decrease the risk of ventilator associated
pneumonia
A nurse is reviewing ECG strips for several clients. Which of the following images
should the nurse identify as atrial fibrillation
(cannot insert pictures, read description)
A. multiple irregular and variable waves at the baseline and irregular R to R intervals
B. a rate of 140-180/min
C. a tachycardia with no identifiable P wave and is determined to originate somewhere
other than the ventricles. Rate between 100-280/min
D. a P wave for every QRS, rate is 60-100/min - Answers -A
--
B, Vtach
C, SVT
D, normal sinus
,A nurse is preparing to admit a client who has a new tracheostomy from the operating
room. Which of the following items is the priority for the nurse to have available in the
client's room upon admission
A. Obturator
B. Hydrogen peroxide
C. Sterile gloves
D. Inner cannula - Answers -A
The obturator can be inserted in the stoma in the even of dislodgment or decannulation
to maintain an airway until a new trach tube can be placed. For the first 72 hr following
the insertion of a trach, dislodgement or decannulation is considered an emergency
--
B, used for trach care, but not priority
C, sterile gloves for suctioning or for dressing change, but not priority
D, inner cannula in case it needs to be replaced, but not priority
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 - Answers -C
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, nausea can indicate an acute hemolytic transfusion reaction
B, transfusion reactions include acute hemolytic, febrile, mild allergic, and anaphylactic
D, bradycardia is not an indication
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 - Answers -C
, Altered taste is a result of the release of metabolites by dead cells
--
A, client may have hair loss at the treatment site on the chest
B, client might have skin changes, such as dryness and increased sensitivity
D, avoid heat exposure
A nurse is preparing to administer a unit of packed RBCs to a client who has anemia.
Which of the following actions should the nurse plan to take (select all that apply)
A. Obtain pre-transfusion temperature
B. Prime the IV tubing with lactated Ringer's
C. Instruct an assistive personnel to monitor the client during the transfusion
D. Verify the client's blood type with a second nurse
E. Use a 20 gauge IV needle for venous access - Answers -A, D, E
--
A, complete assessment prior to transfusion
B, prime tubing with a solution that does not cause hemolysis of PRBCs. No LR or 5%
dextrose!
C, nurse should remain with pt for first 15 minutes of transfusion
D, verify identification, blood compatibility, and expiration of product with second nurse
E, the nurse should use a large bore needle to transfuse the PRBCs to reduce the risk
of cell hemolysis and obstruction of flow
A nurse is reviewing the laboratory findings for a client who is dehydrated. Which of the
following BUN levels should the nurse expect
A. 3.6 mg/dl
B. 8 mg/dL
C. 18.7 mg/dL
D. 26 mg/dL - Answers -D
Normal range is 10-20, and elevated levels indicates renal disease, dehydration, shock,
excessive protein in the diet, sepsis, glucocorticoid use, GI bleeding, or other conditions
in which blood is reabsorbed from injured tissues
--
A low BUN level can indicate malnutrition, malabsorption, liver disease, fluid overload,
or nephrotic syndrome
