ATI PN Adult Medical Surgical 2023 III | Nurselytic

Questions 83

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ATI PN Adult Medical Surgical 2023 III Questions

Question 1 of 5

What actions should the nurse take?

Correct Answer: A

Rationale: Reminiscence therapy supports cognitive function in Alzheimer's patients.

Question 2 of 5

What interventions should the nurse recommend to include in the plan?

Correct Answer: C

Rationale: Restricting sodium corrects hypernatremia by reducing serum sodium levels.

Extract:

Vital Signs
Nurses’ Notes
Diagnostic Results
Provider’s Prescriptions
Postoperative day 1, 0600:
Temperature: 36.4 C (97.5 F)
Heart rate: 84/min
Respiratory rate: 18/min
Blood pressure: 106/74 mm Hg
Oxygen saturation: 97% on room air
2330:
Temperature: 36.3 C(97.3 F)
Heart rate: 104/min
Respiratory rate: 24/min
Blood pressure: 88/54 mm Hg
Oxygen saturation: 96% on room air
The nurse is continuing to assist in the care of the client.


Question 3 of 5

For each data collection finding, specify if the finding on postoperative day 1 is consistent with hypovolemic shock or pulmonary embolism. Each finding may support more than one disease process or none at all.

OptionsHypovolemic ShockPulmonary Embolism
Respiratory effort
Heart rate
Pain
Blood pressure
Mentation

Correct Answer: B,D

Rationale: Tachycardia (heart rate 104/min) and hypotension (88/54 mm Hg) on day 1 at 2330 are consistent with hypovolemic shock due to fluid loss post-surgery.

Extract:


Question 4 of 5

What position should the nurse place the client in?

Correct Answer: C

Rationale: Fowler's position aids breathing by reducing diaphragm pressure in shortness of breath.

Extract:

Day 1, 1000
Day 1, 1100
Day 1, 1000 - Physical Exam
Day 1, 1030 - Diagnostic Results
• Blood pressure: 92/60 mm Hg

• Pulse: 106/min

• Temperature: 38.3 C (101F)

• Oxygen saturation: 95%


Question 5 of 5

The nurse is collecting data on the client. Which of the following findings require follow-up?

Correct Answer: A,B,C,F

Rationale: Blood pressure of 92/60 mm Hg (hypotension), elevated BUN, abdominal findings, and potassium levels require follow-up due to potential shock, renal dysfunction, or electrolyte imbalance, especially with fever and tachycardia.

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