ATI RN
ATI Nur285 Med Surg Fall Exam Questions
Extract:
Question 1 of 5
The nurse is caring for a client who has had an upper G.I. endoscopy. The client's vital signs must be taken every 30 minutes for two hours after the procedure. The nurse assigns an unlicensed assistant to take the vital signs. Two hours later, the assistant reports to client who was previously afebrile has now developed a temperature of 101.8°F. What should the nurse do in response to this reported data by the unlicensed assistant?
Correct Answer: A
Rationale: A fever following an upper gastrointestinal endoscopy can be a sign of a serious complication, such as perforation, which could cause peritonitis. The nurse should promptly assess the client for other signs of perforation, such as abdominal pain, rigidity, or changes in vital signs.
Question 2 of 5
A patient has a nasogastric (NG) tube following esophagectomy. Following standards of practice, which of the following postoperative instructions should the nurse question the surgeon about?
Correct Answer: C
Rationale: A temperature under 100.5°F is not typically concerning post-surgery, so notifying the physician for this is unnecessary.
Question 3 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 4 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 5 of 5
The nurse is changing the subclavian dressing of a client who is receiving total parenteral nutrition. When assessing the catheter insertion site, the nurse noticed the presence of a yellow drainage from around the sutures that are anchoring the catheter. Which actions should the nurse take first?
Correct Answer: C
Rationale: Obtaining a culture identifies potential infection, applying a sterile dressing maintains cleanliness, and monitoring prevents complications.