ATI RN Adult Medical Surgical 2023 Questions -Nurselytic

Questions 47

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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 PrescriptionAnticipatedNon-essentialContraindicated
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

Correct Answer:

Rationale:

Question 4 of 5

Correct Answer:

Rationale:

Question 5 of 5

Correct Answer:

Rationale:

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