ATI RN
ATI n269 Med Surg Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator-associated pneumonia?
Correct Answer: C
Rationale: Turning the client every 2 hours (not just 4) is a key practice to prevent VAP by improving lung expansion, promoting drainage, and reducing the risk of ventilator-associated pneumonia.
Question 2 of 5
Which of the following assessment findings indicates an emergency and the need for immediate action on the part of the nurse?
Correct Answer: B
Rationale: Tracheal deviation is a medical emergency and typically indicates tension pneumothorax, where air accumulates in the pleural space, shifting the trachea away from the affected side. This can compress the heart and lungs, leading to respiratory and circulatory collapse, requiring immediate action.
Question 3 of 5
A nurse is caring for a client with type 1 diabetes mellitus who reports feeling shaky and having palpitations. When the nurse finds the client's blood glucose to be 48 mg/dL on the glucometer, he should give the client which of the following?
Correct Answer: B
Rationale: 4 oz skim milk: This is the correct choice. Skim milk contains both lactose (a sugar) and protein, which can help raise the blood glucose and stabilize it over a longer period. This is a suitable option for treating mild hypoglycemia.
Question 4 of 5
The nurse assists a patient into which position in preparation for a diagnostic thoracentesis?
Correct Answer: A
Rationale: The optimal position for a thoracentesis is sitting upright with the patient leaning forward slightly, with elbows resting on an over-bed table to help expose the pleural space for access. This position allows gravity to pull the lungs downward and facilitates easier access to the pleural cavity.
Question 5 of 5
After giving 6 oz of orange juice to a patient with hypoglycemia, the nurse finds that the patient's blood glucose level is 65 mg/dl. Which nursing intervention would be the most appropriate in this situation?
Correct Answer: A
Rationale: After administering a carbohydrate source (e.g., 6 oz of orange juice), the nurse should reassess the patient's blood glucose level. If the glucose is still below the target range (typically above 70 mg/dL), the next step is to give an additional 15 grams of carbohydrate to raise the blood sugar. This is a standard approach for mild to moderate hypoglycemia.