ATI RN
ATI RN Medical Surgical 2023 Questions
Extract:
Question 1 of 5
A nurse is planning care for a client who is 12 hr postoperative following a kidney transplant. Which of the following actions should the nurse include in the plan of care?
Correct Answer: A
Rationale: Hourly urine output monitoring detects early graft dysfunction, critical post-kidney transplant. Blood pressure checks should be more frequent, rejection causes other electrolyte issues, and IV opioids are preferred early post-op.
Question 2 of 5
A nurse is caring for a client who has a spinal cord injury and has developed autonomic dysreflexia. Identify the sequence of steps the nurse should take.
Correct Answer: A,B,D,C
Rationale: Autonomic dysreflexia requires: 1) Upright positioning to lower blood pressure; 2) Checking bladder for distension, a common trigger; 3) Antihypertensive administration if severe; 4) Documenting risk to ensure ongoing monitoring.
Question 3 of 5
A nurse is providing teaching for the family of a client who has Alzheimer's disease. Which of the following statements should the nurse include?
Correct Answer: D
Rationale: Structured activities reduce agitation and provide routine for Alzheimer's clients. Darkness may disorient, excessive stimulation can overwhelm, and calendars are less effective due to memory impairment.
Question 4 of 5
A nurse is providing discharge teaching for a client who is receiving treatment for genital herpes. Which of the following statements by the client indicates effectiveness of the teaching?
Correct Answer: D
Rationale: Antiviral therapy for genital herpes (e.g., acyclovir) is typically taken for a defined period, like 3 weeks for initial outbreaks, indicating understanding. Natural condoms don't prevent transmission, antibiotics are ineffective, and lesions resolve faster.
Question 5 of 5
A critical care nurse is assessing a client who has a severe head injury. In response to painful stimuli, the client does not open their eyes, displays decerebrate posturing, and makes incomprehensible sounds. The nurse should assign the client which of the following Glasgow Coma Scale scores?
Correct Answer: D
Rationale: Glasgow Coma Scale: No eye opening (1), decerebrate posturing (abnormal extension, 2), incomprehensible sounds (2) = 1+2+2 = 5, reflecting severe neurological impairment.