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 is 3 hours postoperative following a total knee arthroplasty. Which of the following actions should the nurse take to prevent venous thromboembolism?
Correct Answer: A
Rationale:
Correct
Answer: A. Encourage the client to perform circumduction of the foot.
Rationale:
1. Circumduction of the foot promotes blood flow in the lower extremity, preventing stasis and reducing the risk of venous thromboembolism.
2. This action helps in maintaining muscle tone and preventing blood clots in the postoperative period.
3. Encouraging mobility also prevents complications like deep vein thrombosis.
Summary of Incorrect
Choices:
B. Keeping the client's knees in a flexed position may restrict blood flow and increase the risk of thromboembolism.
C. Massaging the client's legs can dislodge blood clots and lead to embolism.
D. Limiting fluid intake can increase the risk of dehydration and thickening of blood, which can contribute to thrombus formation.
Question 2 of 5
A nurse is caring for a client who requires protective isolation following a hematopoietic stem cell transplant. Which of the following interventions should the nurse implement to protect the client from infection?
Correct Answer: A
Rationale:
Correct
Answer: A
Rationale:
1. Positive pressure airflow in the client's room helps prevent airborne contaminants from entering, reducing the risk of infection.
2. This intervention creates a controlled environment suitable for clients with compromised immune systems.
3. The positive pressure airflow system pushes air out of the room, minimizing the risk of external pathogens entering.
4. This measure is crucial in protective isolation to protect the client from infections during the vulnerable post-transplant period.
Summary:
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Choice B is not directly related to infection prevention in protective isolation.
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Choice C is important for respiratory infections but is not a primary intervention for protective isolation.
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Choice D is relevant but does not directly address infection prevention measures in protective isolation.
Question 3 of 5
A nurse is caring for a client who has left-sided heart failure. Which of the following manifestations should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Crackles. Left-sided heart failure causes fluid buildup in the lungs, leading to pulmonary congestion. Crackles are indicative of fluid in the alveoli, a common sign of pulmonary edema in heart failure. Decreased urine output (
B), daytime oliguria (
C), and halo vision (
D) are not specific to left-sided heart failure. Decreased urine output and oliguria are more associated with kidney dysfunction, while halo vision is related to eye conditions like cataracts.
Question 4 of 5
A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Request an interpreter during the initial assessment. This is the best option because it ensures effective communication between the nurse and the client. By having a professional interpreter present, the nurse can accurately gather information, provide instructions, and address any concerns the client may have. Asking a family member to be present (
A) may not guarantee accurate communication. Familiarizing with sign language (
C) may not be sufficient for complex medical discussions. Using a board with pictures (
D) may not be effective for detailed conversations.
Question 5 of 5
A nurse is planning care for a client who has a new diagnosis of acute pancreatitis. Which of the following interventions should the nurse include in the plan of care?
Correct Answer: B
Rationale: The correct answer is B: Maintain the client on NPO status. In acute pancreatitis, the pancreas is inflamed, leading to digestive enzyme release and potential autodigestion of pancreatic tissue. Keeping the client NPO (nothing by mouth) helps rest the pancreas by reducing stimulation of enzyme secretion. This allows the pancreas to heal and decreases the risk of further complications. Administering antihypertensive medications (
A) is not typically a priority for acute pancreatitis. Placing the client in a supine position (
C) may not directly impact the pancreatitis. Monitoring for hypercalcemia (
D) is important in chronic pancreatitis but not typically a primary intervention in the acute phase.