ATI RN
ATI N200 Med Surg Exam Questions
Extract:
Question 1 of 5
The priority nursing intervention for a client who has a serum sodium level of 154 mEq/L would be:
Correct Answer: C
Rationale: Fluid restriction (
C) corrects hypernatremia. Cardiac monitoring (
A), breath sounds (
B), and safety precautions (
D) are secondary.
Question 2 of 5
The nurse is changing a client's abdominal dressing and notes a separation of the incision line. The underlying tissue is protruding from the wound. The nurse should plan to do which of the following in the initial care of this wound?
Correct Answer: D
Rationale: Saline-soaked dressing (
D) keeps tissue moist. Iodine (
A), irrigation (
B), and dry dressing (
C) risk tissue damage.
Question 3 of 5
The client has right lower lobe pneumonia with a non-productive cough. Which intervention is the nurse's priority?
Correct Answer: B
Rationale: Fluids (
B) thin mucus for clearance. Suctioning (
A) is unnecessary for non-productive cough, right side-lying (
C) may worsen drainage, and codeine (
D) suppresses cough.
Question 4 of 5
The nurse is caring for a patient who returned 4 hours ago from having a lumbar laminectomy. Which change in assessment requires further action?
Correct Answer: C
Rationale: Clear yellow drainage from the Foley catheter is a normal finding postoperatively. Not having a bowel movement immediately after surgery is not unusual due to anesthesia and postoperative medications. Bowel function should be monitored. Numbness in both feet could indicate nerve injury, spinal cord compression, or other complications such as hematoma formation, and requires immediate attention. Pain is expected after surgery, but if the pain level is not well-controlled, it should be addressed. A pain score of 7/10 requires further assessment, but it is not as urgent as bilateral numbness.
Question 5 of 5
An older adult client with chronic respiratory disease tells the nurse it is unnecessary to receive the pneumococcal pneumonia vaccine because the influenza vaccine was just received two months ago. Which response by the nurse is most appropriate?
Correct Answer: A
Rationale: Influenza vaccine doesn't protect against bacterial pneumonia; pneumococcal vaccine (
A) is needed. Full protection (
B), flu causing pneumonia (
C), and carrier prevention (
D) are incorrect.