ATI RN
ATI Med Surg Exam 9 Questions
Extract:
Question 1 of 5
A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery?
Correct Answer: D
Rationale: Fluid and electrolyte imbalance is a common complication of ileostomy surgery because the colon, which is bypassed, is primarily responsible for absorbing fluids and electrolytes. This leads to increased loss through stool, potentially causing dehydration and imbalances in sodium and potassium.
Question 2 of 5
A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery?
Correct Answer: D
Rationale: Fluid and electrolyte imbalance is a common complication of ileostomy surgery because the colon, which is bypassed, is primarily responsible for absorbing fluids and electrolytes. This leads to increased loss through stool, potentially causing dehydration and imbalances in sodium and potassium.
Question 3 of 5
A nurse is assessing a client who is receiving total parenteral nutrition (TPN) therapy via an infusion pump. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Changing the IV tubing every 24 hours is recommended to prevent infection and maintain sterility, as TPN can support bacterial growth (
Choice
C). Blood glucose should be monitored every 4-6 hours, not every 12 hours, due to TPN's high-glucose content affecting blood sugar levels (
Choice
A). IV site dressings should be changed daily or as needed to prevent infection, not every 4 days (
Choice
B). The client should be weighed daily, not every other day, to assess fluid balance and nutritional status (
Choice
D).
Question 4 of 5
A client is diagnosed with a problem involving the inner ear. Which is the most common client complaint associated with a problem involving this part of the ear?
Correct Answer: A
Rationale: Hearing loss is the most common complaint with inner ear problems, as the cochlea is responsible for hearing. Tinnitus is a symptom, pruritus relates to the outer ear, and muffled sounds indicate middle ear issues.
Question 5 of 5
The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis. The client reports a sudden increase in abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the best first action the nurse should take?
Correct Answer: C
Rationale: Reason: Requesting the charge nurse put the client on the surgery schedule is not the best first action, as it does not address the urgency of the situation. The client may have a perforated appendix, which is a life-threatening complication that requires immediate intervention. Reason: Documenting the WBC count from the morning labs is not the best first action, as it does not address the client's current condition. The WBC count may be elevated due to inflammation or infection, but it does not indicate the severity of the problem. Reason: This is the correct choice. Notifying the healthcare provider is the best first action, as it alerts them to the possibility of a perforated appendix and allows them to order appropriate tests and treatments. Reason: Providing an antiemetic is not the best first action, as it does not address the underlying cause of the vomiting. The client may have peritonitis, which is inflammation of the abdominal cavity due to leakage of intestinal contents. An antiemetic may mask this symptom and delay diagnosis and treatment.