Questions 49

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ATI Nur285 Med Surg Fall Exam Questions

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Question 1 of 5

A patient is being treated for bleeding esophageal varices with balloon tamponade. Which of the following nursing actions will the nurse include in the plan of care?

Correct Answer: B

Rationale: Monitoring vital signs frequently is critical in patients with bleeding esophageal varices, as they are at risk for hypovolemic shock. Vital signs should be monitored closely to assess for signs of bleeding, hemodynamic instability, and response to interventions.

Question 2 of 5

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator-associated pneumonia?

Correct Answer: A

Rationale: Brushing the client's teeth with a suction toothbrush every 12 hours is a key intervention to reduce the risk of ventilator-associated pneumonia (VAP). Oral hygiene helps to decrease the accumulation of bacteria in the mouth, which could potentially be aspirated into the lungs and cause infection.

Question 3 of 5

A nurse in a post-anesthesia care unit (PACU) is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?

Correct Answer: C

Rationale: A purplish-colored stoma suggests ischemia or poor circulation, which requires immediate reporting to prevent complications like necrosis.

Question 4 of 5

A nurse is implementing a plan of care for a client who has AIDS with recurring pneumonia. Which of the following actions should the nurse take?

Correct Answer: D

Rationale: Obtaining a sputum culture is a priority to identify the specific pathogen causing the pneumonia and guide antibiotic treatment, especially in an immunocompromised client with AIDS.

Question 5 of 5

The nurse is completing discharge teaching with a patient following an ileostomy. Which statement by the patient indicates the need for more teaching concerning the ileostomy?

Correct Answer: D

Rationale: Some foods may cause blockages or discomfort post-ileostomy, requiring dietary modifications, indicating a need for further teaching.

Similar Questions

A patient with anorexia nervosa shows signs of malnutrition and is prescribed parenteral nutrition. If the client develops refeeding syndrome, what laboratory tests does the nurse expect the healthcare provider to order? (Select all that apply.)
A nurse prepares to replace the nearly empty container of total parenteral nutrition (TPN) for a client when she finds that there has been a delay in receiving the new container of solution from the pharmacy. Which of the following solutions should the nurse infuse until the next container of TPN solution becomes available?
A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions?
Which patient should the nurse assess first after receiving a change-of-shift report?
A nurse in a provider's office is assessing an older adult client whose son reports that the client has been sick with a respiratory illness for the past 6 days. Which of the following assessment findings is a manifestation of pneumonia in the older adult client?

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