ATI RN
ATI N200 Med Surg Exam Questions
Extract:
Question 1 of 5
A client who receives an antihypertensive medication daily is NPO except medications for surgery. The most recent blood pressure recording is 174/88. What action should the nurse take first?
Correct Answer: D
Rationale: Administering antihypertensive (
D) addresses high blood pressure. Notifying (
A), documenting (
B), and relaxation (
C) are secondary.
Question 2 of 5
Which of the following teaching instructions should be included for the patient with newly prescribed opioid analgesic for pain? (SELECT ALL THAT APPLY)
Correct Answer: B,C,E
Rationale: A diet high in fiber is important to prevent constipation, a common side effect of opioid use. Adequate fluid intake helps to prevent dehydration and constipation. Taking a stool softener daily can help mitigate the constipating effects of opioids. While dizziness can occur, clients should be encouraged to maintain an appropriate level of activity with precautions. Taking the opioid with a full glass of water and sitting upright can help prevent esophageal irritation and ensure proper swallowing of the medication.
Question 3 of 5
The nurse is caring for a patient who returned 4 hours ago from having a lumbar laminectomy. Which change in assessment requires further action?
Correct Answer: C
Rationale: Clear yellow drainage from the Foley catheter is a normal finding postoperatively. Not having a bowel movement immediately after surgery is not unusual due to anesthesia and postoperative medications. Bowel function should be monitored. Numbness in both feet could indicate nerve injury, spinal cord compression, or other complications such as hematoma formation, and requires immediate attention. Pain is expected after surgery, but if the pain level is not well-controlled, it should be addressed. A pain score of 7/10 requires further assessment, but it is not as urgent as bilateral numbness.
Question 4 of 5
A client returns to the unit after undergoing a total hip replacement with a cemented prosthesis. Which order should the nurse anticipate regarding weight bearing status?
Correct Answer: A
Rationale: Full weight bearing is often allowed immediately after surgery with a cemented prosthesis to facilitate early mobility.
Toe touch weight bearing is typically reserved for certain types of hip surgeries, not cemented prostheses. Non-weight bearing is usually for surgeries with significant healing time required for the bone. Partial weight bearing may be prescribed in some cases but is less common with cemented prostheses.
Question 5 of 5
A client develops an inflamed, very painful right great toe overnight and the physician diagnoses gout. Treatment with colchicine is begun at 0.6 mg PO every two hours. For which side effect of this drug should the nurse assess?
Correct Answer: B
Rationale: Cold, pale feet are not a typical side effect of colchicine. Diarrhea is a well-known side effect of colchicine, commonly used to treat acute gout flares. The nurse should monitor for gastrointestinal symptoms. Menorrhagia (heavy menstrual bleeding) is not associated with colchicine. Rash is not a common side effect of colchicine but can occur. The nurse should primarily monitor for gastrointestinal symptoms like diarrhea.