ATI RN
RN ATI Adult Medsurg Proctored Exam 2023 With NGN Questions
Extract:
Question 1 of 5
A nurse is assessing a client for fluid volume deficit following lumbar spinal surgery. The nurse should identify which of the following findings as an indication the client is at risk for fluid volume deficit?
Correct Answer: A
Rationale: The correct answer is A: Surgical drain output 300 mL during an 8-hr shift. This finding indicates potential fluid loss, which can lead to fluid volume deficit. Surgical drain output is a direct measure of fluid loss from the body and can help assess the client's fluid status. Bounding peripheral pulses (
B) and neck vein distention (
C) are signs of fluid volume excess, not deficit. Weight gain of 2 kg (4.4 lb) in 24 hours (
D) suggests fluid retention, not deficit.
Question 2 of 5
A nurse is planning preventative strategies for a client who is at risk for pressure injuries. Which of the following actions should the nurse include in the plan?
Correct Answer: A
Rationale: The correct answer is A: Apply moisturizer to damp skin after bathing. Moisturizing helps maintain skin integrity and hydration, reducing the risk of pressure injuries. When skin is damp, it is more receptive to hydration, which can prevent dryness and breakdown. Applying moisturizer also helps to maintain the skin's natural barrier function. Massaging bony prominences (choice
B) can actually increase the risk of pressure injuries by causing friction and shearing forces. Using cornstarch powder (choice
C) can lead to moisture buildup and increase the risk of skin breakdown. Positioning the client at a 90-degree angle in bed (choice
D) is not a recommended preventive strategy for pressure injuries.
Question 3 of 5
A nurse is assessing a client who has a central venous catheter (CVC) with intravenous (IV) fluids infusing. The client suddenly develops shortness of breath, and the nurse notes that the IV tubing and needleless connector device are disconnected. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Close the pinch clamp on the CVC. This action is crucial to prevent air embolism, a potentially life-threatening complication of central venous catheter disconnection. Closing the pinch clamp will stop air from entering the bloodstream and minimize the risk of air embolism. Administering oxygen (
B) is important, but closing the pinch clamp takes priority to prevent immediate harm. Placing the client in Trendelenburg position (
C) is not recommended as it can worsen air embolism by allowing air to travel to the heart. Obtaining emergency IV access (
D) is not the first priority in this situation; preventing air embolism is critical.
Question 4 of 5
A nurse is caring for a client who is intubated and receiving mechanical ventilation for heroin toxicity. Which of the following assessments is the nurses priority?
Correct Answer: C
Rationale: The correct answer is C: Check ABGs. In this scenario, monitoring the client's arterial blood gases (ABGs) is the priority assessment because heroin toxicity can lead to respiratory depression and impaired gas exchange. ABGs provide crucial information about the client's oxygenation and ventilation status, which is essential for managing mechanical ventilation and preventing respiratory complications. Monitoring urine output (
A) is important but not the priority in a client with potential respiratory compromise. Assessing level of consciousness (
B) is significant, but ensuring adequate oxygenation takes precedence. Monitoring for signs of withdrawal (
D) is important but not as urgent as assessing respiratory status.
Question 5 of 5
A nurse is planning care for a client who had a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care?
Correct Answer: B
Rationale: The correct answer is B: Turn the client by log rolling with a turning sheet. This is the correct intervention because after a lumbar laminectomy, it is crucial to protect the surgical site and avoid bending or twisting the spine. Log rolling with a turning sheet helps maintain proper alignment and prevent injury to the surgical area.
Choice A is incorrect because encouraging the client to ambulate independently may put stress on the surgical area.
Choice C is incorrect as positioning the client in a high Fowler's position may also strain the spine.
Choice D is incorrect because applying a heating pad to the lower back can increase the risk of burns and should be avoided near a surgical site.