ATI RN
ATI RN Adult Medical Surgical 2023 Questions Questions
Extract:
Question 1 of 5
A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Request an interpreter during the initial assessment. This is the most appropriate action as it ensures effective communication between the nurse and the client who uses sign language. It upholds the client's right to clear and accurate information regarding their care. Asking a family member (choice
A) may not guarantee accurate communication and could breach confidentiality. Familiarizing oneself with sign language (choice
C) takes time and may not be sufficient for complex medical discussions. Using a board with pictures (choice
D) may not provide the client with the level of detail needed for comprehensive care. Overall, requesting an interpreter is the best choice for ensuring effective communication and respecting the client's rights.
Question 2 of 5
A nurse is planning care for a client who has a cervical spine injury and has a halo traction device in place. Which of the following actions should the nurse plan to take?
Correct Answer: C
Rationale: The correct answer is C: Ensure that there is space for one finger to fit between the vest and the client's skin. This is crucial to prevent pressure ulcers and skin breakdown. Tight fitting of the vest can lead to skin irritation and compromised circulation. A: Applying medicated powder can cause skin irritation and infection. B: Moving the client by holding onto the halo device can cause injury and dislodgement. D: Loosening or tightening screws without proper training can lead to complications.
Question 3 of 5
A nurse on an intensive care unit is planning care for a client who has increased intracranial pressure following a head injury. Which of the following IV medications should the nurse plan to administer?
Correct Answer: C
Rationale: The correct answer is C: Mannitol. Mannitol is an osmotic diuretic that helps reduce intracranial pressure by drawing fluid out of brain tissues. It is commonly used in the management of increased intracranial pressure in clients with head injuries. Propranolol (
A) is a beta-blocker used for hypertension and anxiety, not for reducing intracranial pressure. Dobutamine (
B) is a beta-1 agonist used for cardiac support, not for managing intracranial pressure. Chlorpromazine (
D) is an antipsychotic medication and is not indicated for reducing intracranial pressure.
Question 4 of 5
A nurse is planning care for a client who has bacterial meningitis. Which of the following interventions should the nurse implement?
Correct Answer: D
Rationale: The correct answer is D: Ensure lights are dimmed in the client's room. Dimming the lights can help decrease stimulation and minimize discomfort for a client with bacterial meningitis, as they may be sensitive to light due to photophobia, which is a common symptom in meningitis. It can also help reduce the risk of exacerbating headaches and other symptoms.
Incorrect choices:
A: Initiating airborne precautions is not necessary for bacterial meningitis, as it is not transmitted through the air.
B: Ensuring the client's bed is positioned to greater than 45° is not directly related to the care of a client with bacterial meningitis.
C: Encouraging frequent ambulation may not be appropriate for a client with bacterial meningitis, as they may be too weak or ill to ambulate.
E, F, G: There are no additional choices provided, but they would likely be incorrect as they are not relevant to the care of a client with bacterial meningitis.
Question 5 of 5
A nurse is assessing a client who is postoperative following a transurethral resection of the prostate and is receiving continuous bladder irrigation. The client reports bladder spasms, and the nurse notes a scant amount of fluid in the urinary drainage bag, which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Use 0.9% sodium chloride to perform an intermittent bladder irrigation. In this scenario, the client is experiencing bladder spasms and a scant amount of fluid in the drainage bag, indicating a potential blockage or clot in the catheter. Performing an intermittent bladder irrigation with 0.9% sodium chloride can help to clear the catheter and improve urine flow. This intervention helps prevent further complications such as urinary retention or infection. Encouraging the client to unseat or applying a cold compress may not address the underlying issue of catheter blockage. Securing the catheter to the upper left quadrant does not directly address the current problem and may not improve urine flow.