ATI RN
ATI RN Adult Medical Surgical 2023 Questions Questions
Extract:
Medical History: Cerebrovascular accident (CVA) 2 years ago, Coronary artery disease, Hypertension, Hyperlipidemia. A nurse is reviewing the client's medical record. After reviewing the medical history, the nurse must determine which of the following actions to take.
Question 1 of 5
For each potential provider’s prescription, the nurse must select if the action is Anticipated, Nonessential, or Contraindicated for the client.
| Potential Prescription | Anticipated | Non-essential | Contraindicated |
|---|---|---|---|
| Encourage the client to cough | |||
| Elevate the head of the bed | |||
| Assist the client to the bathroom | |||
| Decrease oxygen to 1.5 L/min via nasal cannula | |||
| Keep the client’s head in a midline position | |||
| Initiate seizure precautions |
Correct Answer: B, A, C, A
Rationale: The correct answer is based on the rationale below:
1. Elevate the head of the bed (
B): This action is Anticipated as it helps prevent aspiration and promotes optimal respiratory function.
2. Encourage the client to cough (
A): Also Anticipated as coughing helps clear secretions and maintain airway patency.
3. Assist the client to the bathroom (
C): This is Non-essential unless there are specific concerns about the client's mobility or urgency.
4. Decrease oxygen to 1.5 L/min via nasal cannula (
A): Contraindicated as it may compromise oxygenation, especially without proper assessment and orders.
Other choices:
- Keeping the client's head in a midline position (E) is not provided in the question stem, so it cannot be evaluated.
- Initiating seizure precautions (F) is not relevant to the client's immediate care based on the information given
Extract:
Question 2 of 5
A nurse is planning care for a client who has a cervical spine injury and has a halo traction device in place. Which of the following actions should the nurse plan to take?
Correct Answer: C
Rationale: The correct answer is C: Ensure that there is space for one finger to fit between the vest and the client's skin. This is crucial to prevent pressure ulcers and skin breakdown. Tight fitting of the vest can lead to skin irritation and compromised circulation. A: Applying medicated powder can cause skin irritation and infection. B: Moving the client by holding onto the halo device can cause injury and dislodgement. D: Loosening or tightening screws without proper training can lead to complications.
Question 3 of 5
A nurse is assessing a client who is postoperative following an open reduction and internal fixation (ORIF) of the femur. Which of the following assessments should be the nurse's priority?
Correct Answer: A
Rationale: The correct answer is A: Neurovascular assessment. This is the priority because the client is postoperative following ORIF of the femur, which puts them at risk for impaired circulation and nerve damage. The nurse needs to assess for signs of compromised blood flow or nerve function, such as changes in sensation, color, temperature, or pulse in the affected limb. If left unaddressed, neurovascular complications can lead to serious consequences like compartment syndrome or permanent damage. The other options are not the priority in this situation: B (Braden scale) assesses risk for pressure ulcers, C (Pain assessment) is important but not the priority over neurovascular status, and D (Morse Fall Risk scale) assesses fall risk which is important but not the priority immediately post-ORIF.
Question 4 of 5
A nurse is providing teaching for a client who is taking isoniazid (INH) for tuberculosis. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: D
Rationale: The correct answer is D: "I will have my liver function tested while I am taking this medication." This is the correct answer because isoniazid (INH) is known to potentially cause liver toxicity. Monitoring liver function tests is crucial to detect any signs of liver damage early.
Choice A is incorrect as INH treatment for tuberculosis typically lasts 6-9 months, not just 1 week.
Choice B is incorrect because antacids can decrease the absorption of INH.
Choice C is incorrect as INH does not typically cause an increase in blood pressure.
Question 5 of 5
A nurse is reviewing the medical record of a client who has nephrotic syndrome. Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Proteinuria. In nephrotic syndrome, there is increased permeability of the glomerular filtration membrane, leading to the loss of protein in the urine, specifically albumin. Hyperalbuminemia (choice
A) is incorrect as albumin is lost in the urine. Decreased serum lipid levels (choice
C) are incorrect because nephrotic syndrome is associated with hyperlipidemia due to altered lipid metabolism. Decreased coagulation (choice
D) is incorrect as nephrotic syndrome is actually associated with a hypercoagulable state due to loss of anticoagulant proteins in the urine.