ATI RN Adult Medical Surgical 2023 IV

Extract:

Question 1 of 5

A nurse on a medical-surgical unit is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement?

A. Use chemical restraints at bedtime.B. Use a bed alarm.C. Move client to a double room.D. Encourage participation in activities that provide excessive stimulation.

Correct Answer: B

Rationale: A bed alarm (
B) alerts staff to wandering, enhancing safety. Chemical restraints (
A) are a last resort, double rooms (
C) may increase confusion, and overstimulation (
D) can exacerbate agitation.

Question 2 of 5

A nurse is caring for a client who has emphysema. Which of the following interventions should the nurse include in the client's plan of care?

A. Administer oxygen at 2 L/min.B. Teach the client a breathing exercise with a longer inhalation phase.C. Encourage use of incentive spirometry for 5 min every 2 hr.D. Limit fluid intake to1,000 mL per day.

Correct Answer: A

Rationale: Low-flow oxygen at 2 L/min (
A) helps maintain adequate oxygenation in emphysema without suppressing respiratory drive. Longer inhalation (
B) is not typical, incentive spirometry duration (
C) is insufficient, and fluid restriction (
D) is not indicated unless specified.

Question 3 of 5

A nurse is teaching a client who has left-sided weakness how to use a quad cane. Which of the following client actions indicates an understanding of the teaching?

A. The client advances the weaker leg forward to the cane.B. The client holds the cane with their left hand.C. The client takes a step with their right foot first.D. The client moves the cane 2 feet ahead.

Correct Answer: A

Rationale: Advancing the weaker leg to the cane (
A) provides stability by aligning support with the weaker side. The cane should be held in the stronger hand (B is incorrect), stepping with the stronger leg first (
C) is not the taught sequence, and moving the cane too far (
D) risks imbalance.

Question 4 of 5

A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse plan to include?

A. Assist the client with toileting at least once every 4 hr.B. Turn off all lights in the client's room at night.C. Place the client's bed at the lowest height.D. Request a prescription for a nightly sedative.

Correct Answer: C

Rationale: A low bed height (
C) reduces fall risk in dementia clients.
Toileting every 2 hours (
A) is more appropriate, complete darkness (
B) may disorient, and sedatives (
D) are not first-line.

Question 5 of 5

A nurse in the PACU is caring for a client. Which of the following assessments is the nurse's priority?

A. Level of consciousnessB. Pain levelC. Respiratory statusD. Surgical site

Correct Answer: C

Rationale: Respiratory status (
C) is critical in PACU to ensure airway patency and oxygenation post-anesthesia. Consciousness (
A), pain (
B), and surgical site (
D) are assessed but are secondary to breathing.

ATI RN Adult Medical Surgical 2023 IV | Nurselytic

Nurselytic

ATI RN

ATI RN