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ATI RN ADULT MEDICAL-SURGICAL NURSING /RN ADULT MEDICAL SURGICAL NURSING ACTUAL EXAM TEST BANK 150 QUESTIONS AND CORRECT DETAILED ANSWERS
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ATI RN ADULT MEDICAL-SURGICAL NURSING /RN ADULT MEDICAL SURGICAL NURSING ACTUAL EXAM TEST BANK 150 QUESTIONS AND CORRECT DETAILED ANSWERS A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the following instructions should the nurse include? -...

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  • November 10, 2024
  • 31
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers

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  • ati rn adult medical surgical nursing r

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  • ATI
  • ATI

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KatelynWhitman

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ATI RN ADULT MEDICAL-SURGICAL NURSING 2024-2025
/RN ADULT MEDICAL SURGICAL NURSING ACTUAL
EXAM TEST BANK 150 QUESTIONS AND CORRECT
DETAILED ANSWERS


A nurse is providing postoperative teaching for a client who had a total knee

arthroplasty. Which of the following instructions should the nurse include? -

ANSWER✔✔-Flex the foot every hour when awake.


Rationale: The nurse should instruct the client to flex the foot every hour to reduce the

risk for thromboembolism and promote venous return.


A nurse is caring for a client who has a pneumothorax and a closed-chest drainage

system. Which of the following findings is an indication of lung re-expansion? -

ANSWER✔✔-Bubbling in the water seal chamber has ceased.


Rationale: Bubbling in the water seal chamber ceases when the lung re-expands.


A nurse is reviewing the medical record of a client who is taking warfarin for chronic

atrial fibrillation. Which of the following values should the nurse identify as a desired

outcome for this therapy? - ANSWER✔✔-INR 2.5


Rationale: Clients receive warfarin therapy to decrease the risk of stroke, myocardial

infarction (MI), or pulmonary emboli (PE) from blood clots. Since warfarin is an


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,anticoagulant, the medication must be monitored to ensure the anticoagulation is

within the therapeutic range and prevent hemorrhage (high levels of anticoagulation)

or stroke, MI, or PE (low levels of anticoagulation). An INR of 2.5 is within the targeted

therapeutic range of 2 to 3 for a client who has atrial fibrillation.


A home health nurse is providing teaching to a client who has a stage 1 pressure injury

on the greater trochanter of his left hip. Which of the following instructions should the

nurse include in the teaching? - ANSWER✔✔-Change position every hour


Rationale: Changing position every 1 to 2 hr decreases pressure on bony prominences.

The nurse should also instruct the client to limit the angle of the hips when in a lateral

position to no more than 30°. This positioning prevents direct pressure on the

trochanter.


A nurse is assessing a client following the completion of hemodialysis. Which of the

following findings is the nurse's priority to report to the provider? - ANSWER✔✔-

Restlessness


Rationale: Using the urgent vs. nonurgent approach to client care, the nurse should

determine that the priority finding to report to the provider is restlessness, which can be

an indication the client is experiencing disequilibrium syndrome. Disequilibrium

syndrome is caused by the rapid removal of electrolytes from the client's blood and can

lead to dysrhythmias or seizures. Other manifestations include nausea, vomiting,

fatigue, and headache.


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,A nurse is caring for a client who is 8 hr postoperative following a total hip

arthroplasty. The client is unable to void on the bedpan. Which of the following actions

should the nurse take first? - ANSWER✔✔-Scan the bladder with a portable ultrasound.


Rationale: The first action the nurse should take using the nursing process is to assess

the client. Scanning the bladder with a portable ultrasound device will determine the

amount of urine in the bladder


A nurse is planning a health promotional presentation for a group of African American

clients at a community center. Which of the following disorders presents the greatest

risk to this group of clients? - ANSWER✔✔-Hypertension


Rationale: When using the safety/risk reduction approach to client care, the nurse

should determine that the disorder with the greatest risk for this group of clients is

hypertension. The prevalence of hypertension is highest among African American

clients, followed by Caucasian clients, and then Hispanic clients.


A nurse is caring for a client who has DKA. Which of the following findings should

indicate to the nurse that the client's condition is improving? - ANSWER✔✔-Glucose

272 mg/dL


Rationale: A glucose reading less than 300 mg/dL indicates improvement in the client's

status.




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, A nurse is caring for a client following extubation of an endotracheal tube 10 min. ago.

Which of the following findings should the nurse report to the provider immediately? -

ANSWER✔✔-Stridor


Rationale: Using the urgent vs. nonurgent approach to client care, the nurse should

determine that the priority finding is stridor. Stridor can indicate a narrowing airway or

possible obstruction caused by edema or laryngeal spasms. The nurse should report the

finding immediately and implement an intervention.


A nurse is caring for a client who had a nephrostomy tube inserted 112 hr ago. Which of

the following findings should the nurse report to the provider? - ANSWER✔✔-The

client reports back pain


Rationale: The nurse should notify the provider if the client reports back pain, which

can indicate that the nephrostomy tube is dislodged or clogged.


A nurse is admitting a client who has active TB. Which of the following types of

transmission precautions should the nurse initiate? - ANSWER✔✔-Airborne


Rationale: Airborne precautions are required for clients who have infections due to

micro-organisms that can remain suspended in air for lengthy periods of time, such as

tuberculosis, measles, varicella, and disseminated varicella zoster.


A nurse is planning care for a client who has a sealed radiation implant for cervical

cancer. Which of the following interventions should the nurse include in the plan of

care? - ANSWER✔✔-Keep a lead-lined container in the client's room
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