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ATI PN adult Medical Surgical 2020 with NGN Exam 3 Questions

Extract:


Question 1 of 5

A nurse is assisting in the care of a client who had an ischemic stroke. Which of the following observations by the nurse indicates a need for an occupational therapy referral?

Correct Answer: D

Rationale: Exhaustion during ADLs like brushing teeth indicates a need for occupational therapy.

Question 2 of 5

A nurse is assisting with the care of a client who is receiving penicillin via intermittent IV bolus. Which of the following should the nurse recognize as a clinical manifestation of anaphylaxis?

Correct Answer: B

Rationale: Pruritus is a common early sign of an allergic reaction, potentially indicating anaphylaxis.

Question 3 of 5

A nurse is contributing to the plan of care for a client who has developed an infectious wound with foul-smelling drainage. Which of the following actions should the nurse include in the plan of care?

Correct Answer: C

Rationale: Discarding soiled supplies outside the room prevents the spread of infection.

Question 4 of 5

A nurse is caring for a client who is 3 days postoperative following an ileostomy placement. Which of the following findings should the nurse report to the provider?

Correct Answer: A

Rationale: A retracting stoma may indicate complications like ischemia, requiring immediate reporting.

Question 5 of 5

A nurse is caring for an older adult client who has heart failure. Which of the following findings should the nurse report to the provider?

Correct Answer: D

Rationale: A PaCO2 of 55 mm Hg indicates respiratory acidosis, suggesting worsening heart failure.

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