ATI RN Adult Medical Surgical 2023 IV

Extract:

Question 1 of 5

A nurse is assessing a client for a positive Chvostek's sign following a thyroidectomy. Which of the following areas on the client's head should the nurse tap to assess the client for tetany? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Correct Answer: B

Rationale: The Chvostek's sign is elicited by tapping the facial nerve below the zygomatic arch, anterior to the earlobe. No specific choice is provided in the document, but the correct area is critical to assess for hypocalcemia post-thyroidectomy, which can cause tetany.

Question 2 of 5

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take first?

A. Clear items from the client's surrounding area. B. Loosen the client's restrictive clothing C. Obtain the client's vital signs. D. Lower the client to the floor.

Correct Answer: D

Rationale: Lowering the client to the floor (
D) prevents injury from falls during a seizure and is the priority. Clearing items (
A) and loosening clothing (
B) follow, while vital signs (
C) are not immediate during an active seizure.

Question 3 of 5

A nurse is caring for a client immediately following a cardiac catheterization through the right femoral artery. Which of the following actions should the nurse take?

A. Instruct the client not to bend the affected leg B. Restrict the client's fluid intake. C. Elevate the head of the client's bed to a 45° angle. D. Monitor the client's vital signs once every hour.

Correct Answer: A

Rationale: Keeping the leg straight (
A) prevents bleeding or hematoma at the femoral puncture site. Fluid restriction (
B) is unnecessary, elevating the bed to 45° (
C) may increase bleeding risk, and vital signs (
D) are typically monitored more frequently post-procedure.

Question 4 of 5

A nurse is caring for a client who is experiencing an acute asthma attack. Which of the following should the nurse identify as a contributing factor to the client's manifestations?

A. Decreased responsiveness of airways to allergens B. Suppressed bronchiolar inflammatory response C. Acute loss of alveolar elasticity D. Inability to exhale retained carbon dioxide

Correct Answer: D

Rationale: Inability to exhale retained CO2 (
D) causes air trapping and hyperinflation in asthma due to bronchoconstriction. Airway responsiveness increases (A is incorrect), inflammation is heightened (B is incorrect), and alveolar elasticity loss (
C) is not acute in asthma.

Question 5 of 5

A nurse is caring for a client who has emphysema. Which of the following interventions should the nurse include in the client's plan of care?

A. Administer oxygen at 2 L/min. B. Teach the client a breathing exercise with a longer inhalation phase. C. Encourage use of incentive spirometry for 5 min every 2 hr. D. Limit fluid intake to1,000 mL per day.

Correct Answer: A

Rationale: Low-flow oxygen at 2 L/min (
A) helps maintain adequate oxygenation in emphysema without suppressing respiratory drive. Longer inhalation (
B) is not typical, incentive spirometry duration (
C) is insufficient, and fluid restriction (
D) is not indicated unless specified.

ATI RN Adult Medical Surgical 2023 IV | Nurselytic

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ATI RN

ATI RN