ATI RN
ATI Medsurg Proctored Final Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is 2 hours postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view to be an indication of a postoperative complication?
Correct Answer: D
Rationale: The correct answer is D: Output of burgundy colored urine. This indicates possible hemorrhage, a serious complication post-TURP. Dark amber urine (
A) may suggest dehydration. Clear, light pink urine (
B) is expected due to bladder irrigation post-TURP. Bright red urine (
C) is common initially but should decrease over time. Burgundy colored urine (
D) indicates active bleeding and requires immediate intervention.
Question 2 of 5
A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?
Correct Answer: A
Rationale: The correct answer is A because DIC is characterized by abnormal coagulation involving fibrinogen. In septic shock, the body's response triggers widespread activation of the coagulation system, leading to the consumption of clotting factors like fibrinogen. This results in the formation of microclots throughout the body, leading to organ dysfunction.
Choices B, C, and D are incorrect as DIC is not caused by increased fibrinogen levels, a reduction in platelet production, or a decrease in clotting factors. It is essential for the nurse to emphasize the role of abnormal coagulation involving fibrinogen in DIC to help the client understand the pathology and potential complications associated with septic shock.
Question 3 of 5
A nurse assesses a client 2 hours after TURP. What indicates a complication?
Correct Answer: B
Rationale: The correct answer is B: Burgundy-colored urine output. This indicates a complication post-TURP due to potential bleeding. Clear urine output (
A) is normal. Mild pain at the incision site (
C) is expected. Temperature of 98.6°F (
D) is within normal range.
Question 4 of 5
A nurse is caring for a client who is HIV positive and is one day postoperative following an appendectomy. The nurse should wear a gown as personal protective equipment when taking which of the following actions?
Correct Answer: D
Rationale: The correct answer is D: Completing a dressing change. When completing a dressing change for a client who is HIV positive and postoperative, the nurse should wear a gown as personal protective equipment to prevent potential exposure to blood or body fluids. This is crucial for infection control and to protect both the nurse and the client.
Choice A: Changing the client's linens does not necessarily require wearing a gown unless there is a risk of exposure to blood or body fluids.
Choice B: Administering oral medications does not require wearing a gown as there is no risk of exposure to blood or body fluids.
Choice C: Taking vital signs also does not require wearing a gown unless there is a possibility of exposure to blood or body fluids during the procedure.
In summary, completing a dressing change involves the risk of exposure to blood or body fluids, hence the need for wearing a gown. Other actions listed do not carry the same level of risk, therefore do not require the use of a gown as personal protective
Question 5 of 5
A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority?
Correct Answer: A
Rationale: The correct answer is A: Administering a nebulized beta-adrenergic. This is the highest priority because it helps to rapidly dilate the bronchioles, improving airflow and oxygenation in the client. This immediate action is crucial in managing an acute asthma exacerbation and can prevent respiratory distress. Providing supplemental oxygen (
B) is important but not the highest priority. Administering an intravenous corticosteroid (
C) is beneficial for reducing inflammation but takes longer to take effect compared to a beta-adrenergic. Encouraging the client to use their inhaler (
D) is helpful, but in an acute exacerbation, a nebulized beta-adrenergic is more effective for immediate relief.