ATI RN
ATI N 1201222 Med Surg Final Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has end-stage kidney disease (ESKD) and reports having shortness of breath and swelling in his lower extremities. Upon assessment, the nurse notes the client has crackles in his lungs and elevated blood pressure. The nurse should suspect which of the following based on the client's manifestations?
Correct Answer: C
Rationale: Hypervolemia causes edema, shortness of breath, crackles, and hypertension in ESKD due to fluid retention. Hyperkalemia and hyponatremia affect electrolytes, hypovolemia causes hypotension.
Question 2 of 5
A nurse is planning care for an older adult client at risk for developing pressure ulcers. Which intervention is appropriate to maintain skin integrity?
Correct Answer: A
Rationale: Repositioning every 2 hours reduces pressure on vulnerable areas, preventing ulcers. Massaging bony prominences risks tissue damage, high Fowler's aids respiration, and cornstarch may cause irritation.
Question 3 of 5
A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: Waiting 30 minutes allows the oral cavity to return to normal temperature, ensuring an accurate reading. Immediate measurement, documentation without action, or warm water skews results.
Question 4 of 5
A nurse is providing discharge teaching for a client who has pulmonary edema and is about to start taking furosemide. Which of the following instructions should the nurse include?
Correct Answer: C
Rationale: Furosemide, a diuretic, causes potassium loss through increased urination, risking hypokalemia. Eating potassium-rich foods helps maintain electrolyte balance. Swelling is alleviated by furosemide, not caused; bedtime dosing may cause nocturia, disrupting sleep; and aspirin is not standard for furosemide-related headaches.
Question 5 of 5
A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having an increased risk of aspiration while eating (select all that apply)?
Correct Answer: B,D,E
Rationale: Cerebrovascular accident (stroke) causes dysphagia, increasing aspiration risk. Head and neck trauma damages swallowing structures, and recent postoperative clients under anesthesia have impaired airway reflexes. Lactose intolerance and diarrhea affect digestion, not swallowing.