ATI RN
ATI RN Adult Medical Surgical 2023 Questions Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is postoperative following an endoscopy with moderate (conscious) sedation. Which of the following assessment findings is the nurse's priority?
Correct Answer: A
Rationale: The correct answer is A: Gag reflex. The priority assessment for a client post-endoscopy with sedation is to ensure their airway is intact. The presence of a gag reflex indicates the airway protection mechanism is functional, reducing the risk of aspiration. Monitoring warmth of extremities, temperature, and pain level are important but secondary assessments compared to airway patency. Ensuring the client's safety and preventing respiratory compromise take precedence in this situation.
Question 2 of 5
A nurse is caring for a client who has cervical cancer and is receiving brachytherapy. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Instruct visitors to remain 3 feet from the client. This is because brachytherapy involves the internal placement of radioactive sources close to the tumor. By instructing visitors to remain 3 feet away, the nurse helps minimize their exposure to radiation.
A: Discarding the radioactive device in the client's trash can is incorrect as it can pose a radiation hazard to others.
B: Limiting time for visitors to 2 hours per day does not directly address radiation exposure concerns.
D: Keeping soiled bed linens in the client's room does not address radiation safety for visitors.
In summary, option C is the best choice as it directly addresses radiation safety for visitors during brachytherapy treatment.
Question 3 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 first?
Correct Answer: C
Rationale: The correct answer is C: Turn the client on their side. This is the first action the nurse should take during a seizure to prevent aspiration and maintain an open airway. Turning the client on their side helps to prevent choking and allows any fluids to drain out of the mouth. Obtaining vital signs (
A) and performing a neurologic check (
B) can be done after ensuring the client's safety. Notifying the rapid response team (
D) is important in some situations, but the immediate priority is to protect the client from harm during the seizure.
Question 4 of 5
A nurse is caring for a client who is 3 hr 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 feet.
Rationale: Circumduction of the feet involves moving the feet in a circular motion, which helps promote blood circulation and prevent stasis in the lower extremities. This movement aids in preventing venous thromboembolism by reducing the risk of blood clots forming in the legs postoperatively. Encouraging this activity is crucial in maintaining vascular health and preventing complications.
Summary of Incorrect
Choices:
B: Keeping the client's knees in a flexed position while in bed may lead to decreased circulation and increase the risk of venous stasis.
C: Massaging the client's legs every 4 hours can dislodge blood clots and increase the risk of embolism.
D: Limiting fluid intake can lead to dehydration, which can increase the risk of clot formation due to thicker blood consistency.
Question 5 of 5
A nurse working in an outpatient clinic is planning a community education program about reproductive cancers. The nurse should identify which of the following manifestations as a possible indication of cervical cancer?
Correct Answer: A
Rationale: The correct answer is A: Painless vaginal bleeding. Cervical cancer can present with abnormal vaginal bleeding, which may include bleeding between periods, after intercourse, or post-menopause. This is due to the abnormal growth of cells in the cervix. Frequent diarrhea (
B), urinary hesitancy (
C), and unexplained weight gain (
D) are not typical manifestations of cervical cancer. Diarrhea and urinary hesitancy are more commonly associated with gastrointestinal or urinary tract issues, while unexplained weight gain can be linked to various factors such as hormonal imbalances or dietary changes.