Questions 60

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ATI n269 Med Surg Exam Questions

Extract:


Question 1 of 5

A nurse is caring for a client who is 1 day postoperative following a transsphenoidal hypophysectomy. While assessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the following should be the nurse's initial action?

Correct Answer: D

Rationale: Checking the drainage for glucose is the most appropriate initial action. Clear drainage from the nasal packing could indicate a CSF leak, which is a complication that can occur after transsphenoidal surgery. CSF contains glucose, so testing for glucose in the drainage will help determine if it is CSF.

Question 2 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 3 of 5

A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds?

Correct Answer: A

Rationale: Wheezes are continuous, high-pitched musical sounds produced by the narrowing of airways, commonly heard in conditions like asthma. They occur mainly during exhalation and are indicative of airflow obstruction.

Question 4 of 5

A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see?

Correct Answer: B

Rationale: In metabolic acidosis, the pH is expected to be below 7.35 because metabolic acidosis indicates an accumulation of acid or loss of bicarbonate, which lowers the blood pH.

Question 5 of 5

A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions by the client indicates an understanding of the teaching?

Correct Answer: C

Rationale: The client holds his breath for 10 seconds after inhaling the medication: This is the correct action. Holding the breath allows the medication to settle in the lungs, enhancing its therapeutic effect.

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