ATI RN
ATI n269 Med Surg Comprehensive Exam Questions
Extract:
Question 1 of 5
A nurse is planning care for a client who has deep vein thrombosis of the lower leg. Which of the following interventions should the nurse include in the plan of care?
Correct Answer: B
Rationale: Keeping the client's affected leg elevated while in bed helps reduce swelling and promotes venous return, which is important in managing DVT.
Question 2 of 5
A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: The first action should be to check the client's vital signs. Nausea and weakness are common symptoms of digoxin toxicity, which can cause bradycardia, arrhythmias, and other life-threatening complications. Checking the vital signs, particularly the heart rate, is critical to assess if the client is experiencing digoxin toxicity.
Question 3 of 5
A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make?
Correct Answer: B
Rationale: Warfarin takes several days to reach a therapeutic effect, so heparin is continued initially to provide immediate anticoagulation until the warfarin becomes effective.
Question 4 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 5 of 5
Which intervention would the nurse implement as the priority when providing care for a patient with a ventriculostomy to measure increased intra-cranial pressure (ICP) caused by a brain tumor?
Correct Answer: B
Rationale: Strict aseptic technique with all procedural dressing changes is the priority intervention. A ventriculostomy is an invasive procedure that introduces the risk of infection, which can significantly worsen the patient's condition. Preventing infection is crucial for maintaining the integrity of the ventriculostomy and ensuring accurate ICP measurements.