ATI RN
ATI n269 Med Surg Comprehensive Exam Questions
Extract:
Question 1 of 5
A nurse is assessing the elastic bandage on the stump of a client who had a right below-the-knee amputation. Which of the following findings should the nurse identify as a complication?
Correct Answer: B
Rationale: Pitting edema around the stump dressing is a complication. This could indicate poor circulation, infection, or fluid retention, which requires prompt assessment and intervention to prevent further complications.
Question 2 of 5
A nurse is caring for a client who had a left hip arthroplasty. Which of the following interventions should the nurse use to prevent dislocation?
Correct Answer: D
Rationale: Maintaining a foam wedge between the legs is the most effective intervention to prevent hip dislocation. The wedge keeps the hips in proper alignment and prevents excessive internal rotation or adduction, which are common causes of dislocation after hip arthroplasty.
Question 3 of 5
A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make?
Correct Answer: B
Rationale: Warfarin takes several days to reach a therapeutic effect, so heparin is continued initially to provide immediate anticoagulation until the warfarin becomes effective.
Question 4 of 5
For each potential precaution, click to specify if the precaution is indicated or contraindicated for a client who has had a total hip arthroplasty.
| Options | Indicated | Contraindicated |
|---|---|---|
| Request an antiemetic medication | ||
| Encourage the client to cough and deep breathe every 2 hr | ||
| Ensure an abductor pillow is in place while the client is in bed | ||
| Anticipate the administration of antibiotics | ||
| Obtain a culture of the drainage from the surgical site |
Correct Answer: B,C,D,E
Rationale: Encouraging coughing and deep breathing, using an abductor pillow, administering antibiotics, and obtaining a culture are indicated to prevent respiratory complications, hip dislocation, and infections. Antiemetics are contraindicated unless nausea is present.
Question 5 of 5
A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions?
Correct Answer: C
Rationale: Increasing fluid intake is the most effective way to thin respiratory secretions. Fluids help to hydrate the mucous membranes, making the mucus less thick and easier to clear.