ATI RN Adult Medical Surgical 2023 V

Extract:

Question 1 of 5

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take first?

A. Loosen the client's restrictive clothing.B. Obtain the client's vital signs.C. Lower the client to the floor.D. Clear items from the client's surrounding area.

Correct Answer: C

Rationale: Lowering the client to the floor prevents injury from falling, the priority during a seizure.

Question 2 of 5

A nurse is planning care for a client who has a seizure disorder. Which of the following equipment should the nurse place in the client's room?

A. Oral airwayB. Tongue bladeC. NG tubeD. Wrist restraints

Correct Answer: A

Rationale: An oral airway can maintain airway patency during a seizure if inserted safely post-seizure.

Question 3 of 5

A nurse is providing teaching to a client who is to start furosemide therapy for heart failure. Which of the following statements indicates that the client understands a potential adverse effect of this medication?

A. I'll check my blood pressure so it doesn't get too high.B. I'm going to include more cantaloupe in my diet.C. I will try to limit foods that contain saltD. I will check my pulse before I take the medication.

Correct Answer: C

Rationale: Limiting salt helps prevent fluid retention, a side effect furosemide manages in heart failure.

Question 4 of 5

A nurse is caring for a client who has a chest tube. The client asks why the fluid in the water-seal chamber rises and falls. Which of the following statements should the nurse make?

A. Suction pressure that is too high causes this.B. Your breathing pattern causes this.C. This means your lung is fully re-expanded.D. This indicates a possible air leak.

Correct Answer: B

Rationale: The rise and fall (tidaling) in the water-seal chamber reflect normal respiratory pressure changes during breathing.

Extract:

Medical History
• Dehydration
• Hyperlipidemia
• Hypertension
• Coronary artery disease (CAD)

Diagnostic Results

• WBC count 14,000/mm3 (5,000 to 10,000/mm3)
• Hgb 14 g/dL (12 to 16 g/dL)
• Hct 40% (34 to 47%)
• Sodium 132 mEq/L (136 to 146 mEq/L)
• Potassium 6.2 mEq/L (3.5 to 5 mEq/L)
• Calcium 10 mg/dL (9 to 10.5 mg/dL)
• BUN 20 mg/dL (10 to 20 mg/dL)
• Albumin 2.8 g/dL (3.5 to 5 g/dL)
• Fasting blood glucose 140 mg/dL (74 to 106 mg/dL)
• Triglycerides 134 mg/dL (34 to 160 mg/dL)

Nurses' Notes
Client is lying in bed. Awake, alert, and oriented to time, place, and person. Client is febrile and reports weakness. Receiving TPN via central line in left antecubital. Client is NPO and has had diarrhea x3 in past 4 hr. Crackles auscultated in posterior lobes. Client has a productive cough and sputum is yellow in color. Client receiving 2 U/min oxygen via nasal cannula with an oxygen saturation of 90%. Abdomen is distended and tender. Active range of motion to all extremities. Denies pain at this time.

Question 5 of 5

A nurse is caring for a client who is receiving TPN. Which of the following actions should the nurse take? For each potential nursing intervention, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client.

Options	Anticipated	Nonessential	Contraindicated
Notify provider to increase TPN rate/hr.
Decrease the client's oxygen to 1.5 L/min oxygen via nasal cannula.
Obtain client weight twice daily.
Request a prescription for insulin.
Request an antibiotic to be administered.
Have 3 nurses verify the TPN solution prescription.

Correct Answer: C,D,E

Rationale: Weight monitoring tracks fluid balance, insulin addresses hyperglycemia, and antibiotics treat suspected infection (fever, elevated WB
C).

ATI RN Adult Medical Surgical 2023 V | Nurselytic

Nurselytic

ATI RN

ATI RN