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
Correct Answer:
Rationale:
Question 3 of 5
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Question 4 of 5
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Question 5 of 5
Correct Answer:
Rationale: