ATI RN
ATI Medical Surgical Proctored Exam 2023 With NGN Questions and Correct Answers Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia. Which of the following assessment findings requires immediate intervention by the nurse?
Correct Answer: A
Rationale: The correct answer is A. Capillary refill time of 6 seconds in the toe indicates poor circulation, which is a concerning finding post-surgery with an external fixator. Immediate intervention is needed to prevent complications like tissue ischemia.
Choices B, C, and D do not require immediate intervention as they are within normal limits postoperatively. Blood in the drain is expected, the temperature is normal, and pain level 7 is manageable with appropriate pain management.
Question 2 of 5
A nurse enters a client's room and observes the client having a tonic-clonic seizure. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct action is to turn the client on their side (
Choice
C) during a tonic-clonic seizure to prevent aspiration and maintain a clear airway. This position helps saliva or vomit to drain out of the mouth, reducing the risk of choking. Obtaining vital signs (
Choice
A) and performing a neurologic check (
Choice
B) can wait until after the seizure is over. Notifying the rapid response team (
Choice
D) is not necessary for a single seizure unless complications arise.
Question 3 of 5
A nurse is caring for a client who has a herniated disc and is scheduled for a peripheral nerve block. The client tells the nurse, 'I am afraid to have this procedure.' Which of the following responses should the nurse make?
Correct Answer: D
Rationale:
Rationale: Option D is correct as it acknowledges the client's fear and opens the door for a discussion about their concerns, allowing the nurse to address them. It shows empathy and promotes client-centered care. Option A focuses solely on needles, which may not address the client's overall fear. Option B dismisses the client's feelings without addressing their fear. Option C asks for the reason but may not actively engage in addressing the fear. Overall, option D is the best choice as it demonstrates active listening and a willingness to address the client's specific concerns.
Question 4 of 5
A nurse on the medical-surgical unit is caring for a client who has a seizure disorder. Which of the following interventions should the nurse include in the plan of care?
Correct Answer: C
Rationale: The correct answer is C: Maintain peripheral IV access. This is important for clients with seizure disorders as they may require immediate administration of medications during or after a seizure. IV access allows for quick drug delivery.
Choice A is incorrect because padding the bed rails is not a standard intervention for seizure disorder.
Choice B is incorrect because a padded tongue blade is not necessary for managing seizures.
Choice D is incorrect because teaching assistive personnel to apply restraints is not a recommended intervention for clients with seizure disorders.
In summary, maintaining peripheral IV access is crucial for prompt medication administration during seizures, while the other choices are not directly related to managing seizures in this context.
Question 5 of 5
A nurse is caring for a client who has a new onset of hyperglycemic hyperosmolar state (HHS). Which of the following interventions by the nurse is the highest priority?
Correct Answer: D
Rationale: The correct answer is D: Initiate IV fluid replacement. In hyperglycemic hyperosmolar state (HHS), the client is severely dehydrated due to high blood glucose levels. IV fluid replacement is the highest priority to rehydrate the client and improve circulation. Administering insulin (
A) is important but not the highest priority as fluid replacement takes precedence. Teaching the client about manifestations of HHS (
B) is important for long-term management but not the immediate priority. Measuring urinary output (
C) is important to assess renal function but not as critical as rehydrating the client.