ATI RN
ATI Med Surg Exam 9 Questions
Extract:
Question 1 of 5
The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis. The client reports a sudden increase in abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the best first action the nurse should take?
Correct Answer: C
Rationale: Notifying the healthcare provider is critical as these symptoms suggest a perforated appendix, a life-threatening condition requiring immediate intervention.
Question 2 of 5
A client with a newborn asks about the lesion on her child's head. After assessing the skin, which response will the nurse offer to the client?
Correct Answer: A
Rationale: The lesion is likely a hemangioma, a benign vascular tumor that typically resolves over time without intervention.
Question 3 of 5
A nurse is assisting a client with a visual impairment to use the restroom. Which of the following actions will the nurse take to prevent complications?
Correct Answer: D
Rationale: Standing slightly in front and to one side of the client prevents collisions or falls by guiding them safely. Increasing voice volume, lowering bed rails prematurely, or using gestures are inappropriate for visually impaired clients.
Question 4 of 5
The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the primary health care provider?
Correct Answer: B
Rationale: Reason: Soft pasty stool is normal for a transverse colostomy, as the stool has not reached the sigmoid colon where most of the water is absorbed. Reason: This is the correct answer because purple discoloration of the stoma indicates ischemia or necrosis, which can lead to infection, perforation, or sepsis. It requires urgent intervention. Reason: Stoma is beefy red is a normal finding for a healthy stoma, as it indicates adequate blood supply and healing. Reason: There is skin excoriation around the stoma is a common complication of a colostomy, as the stool can irritate the skin. It can be managed with proper skin care and appliance fitting.
Question 5 of 5
A blind client reports that they are having difficulty with sleep that is affecting their daytime activities. Which of the following will the nurse include in her plan of care for the client?
Correct Answer: D
Rationale: Reason: This is incorrect because a referral to a sleep study program is not the most appropriate plan of care for a blind client who has difficulty with sleep. A sleep study program is used to diagnose and treat sleep disorders such as sleep apnea, narcolepsy, or restless legs syndrome. Reason: This is incorrect because assisting the client to see if a night shift job is available is not a helpful plan of care for a blind client who has difficulty with sleep. A night shift job can disrupt the circadian rhythm and worsen the sleep quality and quantity of the client. Reason: This is incorrect because institution of opioids and sedatives is not a safe plan of care for a blind client who has difficulty with sleep. Opioids and sedatives can cause addiction, dependence, tolerance, and withdrawal symptoms. They can also impair the respiratory and cognitive functions of the client. Reason: This is the correct choice because education about non-24 disorder is an essential plan of care for a blind client who has difficulty with sleep. Non-24 disorder is a condition where the internal clock of the body does not synchronize with the 24-hour day-night cycle. It can cause irregular sleep patterns, daytime fatigue, and mood disturbances. It is more common in blind people who lack light perception. The nurse should educate the client about the causes, symptoms, and treatments of non-24 disorder.