Questions 69

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ATI n269 Med Surg Comprehensive Exam Questions

Extract:


Question 1 of 5

A nurse is performing a home safety assessment for a client who has experienced a stroke. Which of the following findings are a safety hazard for the client?

Correct Answer: A,B,E

Rationale: Dim lighting, a hot water heater set at 54°C (130°F), and area rugs are safety hazards for a stroke client. Dim lighting increases fall risk, high water temperature can cause burns, and area rugs are tripping hazards. Medications in a clear bag and grab bars are not hazards.

Question 2 of 5

Which action would the nurse take first for a patient with a tracheostomy who appears anxious and is having difficulty in coughing up thick respiratory secretion?

Correct Answer: D

Rationale: Suctioning the tracheostomy is the priority action. The patient is unable to clear thick secretions, and suctioning is necessary to remove the obstruction and improve airway patency, which will also alleviate anxiety and improve oxygenation.

Extract:

Nurse's Notes
The client arrives to the ED and reports a "fluttering" and "racing" heartbeat. The client also reports dizziness and shortness of breath. Client placed on telemetry, cardiac rhythm is irregular, tachycardic and has unclear P waves.
A nurse is caring for a client in the emergency department (ED).


Question 3 of 5

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Acton to Take: Prepare the client for defibrillation
Obtain a 12 lead ECG
Teach the client how to perform vagal maneuver
Administer adenosine IV push
Administer an anticoagulant
Potential conditions A. Atrial fibrillation B. Supraventricular Tachycardia C. Ventricular fibrillation D. Ventricular tachycardia
Parameters to monitor A. Central nervous system side effects B. Manifestations of stroke C. Prolonged PR interval D. PT/INR E. Hypokalemia

Correct Answer: A,B,E,B,D

Rationale: The client is likely experiencing atrial fibrillation, indicated by irregular, tachycardic rhythm and unclear P waves. Obtaining a 12-lead ECG and administering an anticoagulant are appropriate actions. Monitoring for stroke manifestations and PT/INR assesses progress and anticoagulant therapy effectiveness.

Extract:


Question 4 of 5

A nurse is caring for a client who receives furosemide to treat heart failure. Which of the following laboratory values should the nurse monitor for this client due to this medication?

Correct Answer: D

Rationale: Potassium is the primary laboratory value to monitor when a client is on furosemide, a loop diuretic. Furosemide increases the excretion of potassium, which can lead to hypokalemia. This can cause serious cardiac and muscular complications, so regular monitoring of potassium levels is crucial.

Question 5 of 5

A nurse is caring for a client who is postoperative following an open cholecystectomy. Which of the following actions should the nurse take when caring for the client's Jackson-Pratt (JP) drain?

Correct Answer: A

Rationale: After emptying a Jackson-Pratt drain, the air must be expelled from the bulb to re-establish suction. This helps maintain negative pressure, ensuring the effective drainage of fluid from the surgical site.

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