ATI RN
ATI RN Adult Medical Surgical 2023 Questions Questions
Question 1 of 5
A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia. Which of the following assessment findings requires immediate intervention by the nurse?
Correct Answer: A
Rationale: The correct answer is A because a capillary refill of 6 seconds in the left toe indicates poor circulation, which could lead to ischemia or necrosis in the extremity. Immediate intervention is necessary to prevent further complications.
Choice B is not as urgent as it involves monitoring and managing drainage, which can be addressed after the circulation concern is addressed.
Choice C, an elevated temperature, may indicate infection but is not as immediately life-threatening as poor circulation.
Choice D, pain at the operative site, is important but does not require immediate intervention as it can be managed with pain medication.
Question 2 of 5
A nurse is caring for a client who is postoperative following an endoscopy with moderate (conscious) sedation. Which of the following assessment findings is the nurse's priority?
Correct Answer: A
Rationale: The correct answer is A: Gag reflex. The priority assessment for a client post-endoscopy with sedation is to ensure their airway is intact. The presence of a gag reflex indicates the airway protection mechanism is functional, reducing the risk of aspiration. Monitoring warmth of extremities, temperature, and pain level are important but secondary assessments compared to airway patency. Ensuring the client's safety and preventing respiratory compromise take precedence in this situation.
Question 3 of 5
A nurse is preparing to receive a client from surgery following a transverse colon resection with colostomy placement. The nurse should expect to assess the stoma at which of the following locations? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
Correct Answer:
Rationale:
Correct Answer: B
Rationale: The correct location to assess the stoma following a transverse colon resection with colostomy placement is at location B, which is in the left lower quadrant. This is because the transverse colon is typically located in the upper abdomen, and the stoma would be brought out at the most dependent portion of the colon, which is in the left lower quadrant. Assessing the stoma in this location allows the nurse to monitor for proper stoma function and potential complications.
Summary:
A: Incorrect - Location A is in the right upper quadrant, which is not the typical site for a stoma following a transverse colon resection.
C: Incorrect - Location C is in the left upper quadrant, which is also not the typical site for a stoma after this surgery.
D, E, F, G: Not applicable as they are not relevant to the question.
Question 4 of 5
A nurse is assessing a client who is postoperative following an open reduction and internal fixation (ORIF) of the femur. Which of the following assessments should be the nurse's priority?
Correct Answer: A
Rationale: The correct answer is A: Neurovascular assessment. This is the priority because the client is postoperative following ORIF of the femur, which puts them at risk for impaired circulation and nerve damage. The nurse needs to assess for signs of compromised blood flow or nerve function, such as changes in sensation, color, temperature, or pulse in the affected limb. If left unaddressed, neurovascular complications can lead to serious consequences like compartment syndrome or permanent damage. The other options are not the priority in this situation: B (Braden scale) assesses risk for pressure ulcers, C (Pain assessment) is important but not the priority over neurovascular status, and D (Morse Fall Risk scale) assesses fall risk which is important but not the priority immediately post-ORIF.
Question 5 of 5
A nurse is assessing a client who is taking telmisartan. The nurse should identify that which of the following findings indicates that the medication has been effective?
Correct Answer: B
Rationale: The correct answer is B: Decrease in blood pressure. Telmisartan is an angiotensin II receptor blocker used to treat hypertension. A decrease in blood pressure indicates that the medication is effective in controlling hypertension. This is the desired outcome of telmisartan therapy as it helps reduce the risk of cardiovascular events.
Choices A, C, and D are not directly related to the effectiveness of telmisartan. Blood glucose level and urinary output are not typically influenced by telmisartan, and respiratory rate is not a primary indicator of its effectiveness.
Therefore, the most appropriate indicator of telmisartan's effectiveness in this scenario is a decrease in blood pressure.