ATI RN
ATI RN Adult Medical Surgical 2023 III Questions
Extract:
Question 1 of 5
A nurse is planning care for a client who is postoperative following insertion of an arteriovenous graft in their left forearm. Which of the following actions should the nurse include in the plan of care?
Correct Answer: A
Rationale: Checking the distal pulse ensures adequate circulation and graft patency post-insertion.
Question 2 of 5
A nurse is teaching a client who has AIDS and wishes to continue self-care at home despite living alone. Which of the following actions by the nurse demonstrates client advocacy?
Correct Answer: C
Rationale: Initiating a referral to a home health agency supports the client's ability to maintain self-care at home by ensuring access to necessary resources and assistance.
Question 3 of 5
A nurse is caring for a client immediately following a lumbar puncture. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Lying flat post-lumbar puncture reduces the risk of spinal headache due to cerebrospinal fluid leakage.
Question 4 of 5
A nurse is administering furosemide 80 mg PO twice daily to a client who has pulmonary edema. Which of the following assessment findings indicates to the nurse that the medication is effective?
Correct Answer: D
Rationale: Weight loss indicates effective diuresis, as furosemide reduces fluid overload in pulmonary edema, leading to decreased body weight.
Question 5 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: D,B,A,C
Rationale: Positioning upright reduces blood pressure, emptying the bladder removes the trigger, antihypertensives manage severe hypertension, and documenting ensures future care planning.