NGN ATI RN Adult Medical Surgical Practice & ATI Medical Surgical Proctored 2023 Exams (STUDY BUNDLE PACKAGE WITH COMPLETE SOLUTIONS) Questions and Verified Answers| 100% Correct| Grade A

NGN ATIRN COMPREHENSIVE PREDICTOR RETAKE EXAM 2023/2024 ACTUAL QUESTIONS WITH VERIFIED CORRECT ANSW

1. A nurse is accessing a client who has receives an antibiotics. the nurse should identify which of which of the following findings as an indication of a ... [Show More] possible allergic reaction to the medication a. bradycardia b. headache c. joint pain d. Hypotension 2. A nurse on a mental health unit is caring for a client who has schizophrenia and is experiencing auditory hallucinations telling them to hurt others. The client is refusing to take anti-psychotic medication. Which of the following responses should the nurse make? a. You should plan to take this medication for a few weeks." b. "You will regret it if you do not take this medication. * c. "This medication will help you respond to the voices. d. this medication will help you stop the voices you are hearing. 3. A nurse is providing care for a patient who has depression and is to have electroconvulsive therapy. Which of the following conditions should the nurse identify as increasing the client's risk for complications? a. Hyperthyroidism b. Renal calculi c. Diabetes mellitus d. Cardiac dysrhythmias 4. A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis. Which of the following findings should the nurse report to the provider? a. WBC count 8,000/mm b. Platelets 150,000/mm c. Aspartate aminotransferase 10 units/L d. Erythrocyte sedimentation 75 mm/hr 5. A nurse is suctioning the airway of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following findings should the nurse identify as an indication that suctioning has been effective? a. Presence of a productive cough b. Decreased peak inspiratory pressure c. Thinning of mucous secretions d. Flattening of the artificial airway cuff 6. A nurse is caring for a client who is in seclusion room following violent behavior the client continues to display aggressive behavior. Which of the following actions should the nurse a. Stand within 30cm (1ft) of the client when speaking with them b. Express sympathy for the client's situation. c. Confront the client about his behavior. d. Speak assertively to the client. 7. A nurse is caring for a client who is immediately postoperative following an adrenalectomy to treat Cushing's disease. Which of the following actions is the nurse's priority? a. Reposition the client for comfort every 2 hours b. Observe for any indications of infection c. Document amount and color of the incisional drainage. d. Monitor the client's fluid and electrolytes. 8. A nurse is caring for a client who is scheduled for a surgical procedure and states, "I don't want to have this surgery anymore." Which of the following responses should the nurse make? a. "We can manage your care following the procedure without complications." b. "You have the right to refuse the procedure." c. "Your doctor thinks the surgery is necessary. d. "Let me review the procedure so you can understand what is going to happen." 9. A nurse is evaluating a client who has borderline personality disorder. Which of the following behaviors indicates an improvement in the client's condition? a. Impulsive behaviors b. Decreased clinging behavior c. Liability of mood d. Dependent behavior 10. A nurse is teaching a group of school-age children about healthy snack options. Which of the following snacks should the nurse include? a. Air-popped popcorn b. Milkshake made with whole milk. c. Baked potato chips d. Cheesecake 11. A nurse is providing teaching to a client who has a new prescription for enoxaparin. Which of the following medications for pain relief should the nurse include in the teaching that can be taken concurrently with enoxaparin? a. Naproxen sodium b. Ibuprofen c. acetaminophen d. aspirin 12. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse plan to administer? a. Colchicine b. Lorazepam c. Pregabalin d. Codeine 13. A nurse is caring for a client who has congestive heart failure and is receiving furosemide and digoxin. Which of the following laboratory values indicates that the client is at risk for developing digoxin toxicity? a. Glucose 150 mg/dL b. Magnesium 1.3 c. Potassium 3.1 d. Sodium 134 14. A nurse is caring for a client who had an embolic stroke and has a prescription for alteplase. Which of the following in the client's history should the nurse identify as a contraindication for receiving alteplase? a. Hip arthroplasty 1 week ago b. Obstructive lungs disease c. Retinal detachment d. Acute kidney failure 6 months ago 15. A nurse is providing discharge teaching for a client who has a new implantable cardioverter defibrillator (ICD). Which of the following client statements demonstrates understanding of the teaching? a. "I will soak in the tub rather than showering." b. "I can hold my cellphone on the same side of my body as the ICD." c. "I will wear loose clothing over my ICD." d. "I will avoid using my microwave oven at home because of my ICD." 16. A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25ml/hr. Which of the following interventions should the nurse anticipate? a. Clamp the catheter tubing for 30 min. b. Initiate continuous bladder irrigation. c. Obtain a urine specimen for culture and sensitivity. d. Administer a fluid bolus. 17. A nurse is caring for a client who has experienced a stillbirth. Which of the following actions should the nurse take during the initial grieving process? a. Avoid talking to the client about the newborn b. Discourage the client from allowing friends to see the newborn c. Offer to take pictures of the newborn for the client d. Assure the client that she can have additional children 18. A nurse is caring for a client who has a major burn injury. Which of the following actions is the nurse's priority to prevent wound infection? a. Use sterile dressings for wound care b. Apply topical antibiotics to the client's wounds. c. Place the client in protective isolation d. Maintain consistent hand washing by staff. 19. A nurse is speaking with the caregiver of a client who has Alzheimer's disease. The caregiver states, "Providing constant care is very stressful and is affecting all areas of my life." Which of the following actions should the nurse take? a. Discuss methods of how to communicate with the client about problem solving behaviors. b. Suggest that the caregiver seek a prescription for an antipsychotic medication for the client. c. Assist the caregiver to arrange a daycare program for the client. d. Recommend allowing the client to have time alone in their room throughout the day. 20. A nurse is caring for a client who is 1 hr postpartum and unable to urinate. Which of the following actions should the nurse take? a. Administer a benzodiazepine. b. Perform a fundal massage. c. Place an ice pack on the client's perineum. d. Place the client's hand in warm water. 21. A nurse on a medical-surgical unit is performing medication reconciliation for a newly admitted client. Which of the following actions should the nurse take? a. Compare a list of common medications to treat a condition to the actual prescriptions. b. Compare the prescription to the allergy history of the client c. Compare the medication label to the provider's prescription on three occasions before d. Caodmmpinairsetrtahteiocnlient's list of home medications to the admission prescriptions written for the client. 22. . A nurse is preparing to administer betamethasone to a client who is 25 weeks of gestation and has preterm labor. Which of the following findings should the nurse identify as an adverse effect of this medication? a. Hyperglycemia b. Uterine contractions c. Proteinuria d. Hypotension 23. A nurse is preparing to obtain a blood sample from a client who has a central venous catheter. Which of the following actions should the nurse take? (SATA) a. Apply a tourniquet above the catheter insertion site. b. Access the catheter using a large bore needle. c. Aspirate for blood return to access catheter patency. d. Flush the catheter with 0.9% sodium chloride. e. Apply force when resistance is met while flushing the catheter. 24. A nurse is preparing to perform a dressing change on a preschooler. Which of the following actions should the nurse take to prepare the child for the procedure? a. Explain in simple terms how the procedure will affect the child. b. Ask the parents to wait outside the room during the procedure. c. Limit teaching sessions about the procedure to 20 min. d. Instruct the child in deep-breathing methods prior to the procedure. 25. A nurse is performing wound care for a client who has an abdominal incision. Which of the following techniques should the nurse implement? a. Irrigate the wound using a 10-ml syringe. b. Cleanse the wound starting at the bottom and moving upward. c. Cleanse the insertion site of the drain using a circular motion towards the center. d. Irrigate the wound with a low-pressure flow of solution. 26. A nurse on an antepartum unit is prioritizing care for multiple clients. Which of the following clients should the nurse see first? a. A client who is at 36 weeks of gestation and has a biophysical profile score of 8 b. A client who has preeclampsia and reports a persistent headache. c. A client who has pregestational diabetes mellitus and an A1C of 6.2 d. A client who is 28 weeks gestation and reports leukorrhea [Show Less]

ATI RN Adult Medical Surgical Practice exam questions and answers latest update 2023 -2024 with NGN

A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurse's priority? Anorexia Abdominal pain radiating to... [Show More] the right shoulder Tachycardia Rebound abdominal tenderness: Tachycardia -Tachycardia is a manifestation of biliary colic, which can lead to shock. The nurse should position the head of the client's bed flat and report this finding immediately 2. A nurse is caring for a client who is undergoing hemodialysis to treat end-stage kidney disease (ESKD). The client reports muscle cramps and tingling sensation in their hands. Which of the following medications should the nurse plan to administer? Epoetin alfa Furosemide Captopril Calcium carbonate: Calcium carbonate 3. A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching? "I will monitor my blood pressure while taking this medication" "I should take a vitamin D supplement to increase the effectiveness of the medication." "I should inform the provider if I experience an increased appetite while taking this medication" "I will decrease the amount of protein in my diet while taking this medication."- : "I will monitor my blood pressure while taking this medication" -monitor their blood pressure while taking this medication because hypertension is a common adverse effect and can lead to hypertensive encephalopathy. Rationale -client requires an adequate intake of iron, folic acid, and vitamin B12 while taking this medication because they are essential to the production of erythrocytes. -increase the amount of protein in their diet while receiving chemotherapy to decrease the risk for infection. 4. The nurse is caring for a group of clients. The nurse should plan to make a referral to physical therapy for which of the following clients? -A client who is receiving preoperative teaching for a right knee arthroplasty. -A client who states they will have difficulty obtaining a walker for home use. -A client who reports an increase in pain following a left hip arthroplasty. -A client who is having emotional difficulty accepting that they have a prosthetic leg.: A client who is receiving preoperative teaching for a right knee arthroplasty. -should make a referral to physical therapy for a client who is receiving preoperative teaching for a knee arthroplasty so the client can begin understanding postoperative exercises and physical restrictions. Rationale -should make a referral to a social worker for walker -should contact the provider for a client who is experiencing increased pain following a left hip arthroplasty. -should refer the client to a counselor to assist with coping with the adjustment to the need of a prosthetic leg. 5. A nurse is providing teaching to a female client who has a history of urinary tract infections (UTIs). Which of the following information should the nurse include in the teaching? Avoid foods that are high in ascorbic acid. Add oatmeal to the water when taking a tub bath. Urinate every 6 hr. Take daily cranberry supplements.: Take daily cranberry supplements -.take cranberry supplements or drink low-fructose cranberry juice because it contains compounds that adhere to the urinary tract wall, decreasing the risk for developing a UTI Rationale -risk for developing UTIs should urinate every 2 to 4 hr. -take showers rather than tub baths because bacteria in the bath water can enter the urethra. -increase intake of ascorbic acid to acidify the urine. 6. A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new prescription for metformin. Which of the following statements by the client indicates an understanding of the teaching? "I will monitor my blood sugar carefully because the medication increases the secretion of insulin." "I should take this medication with a meal." "I can expect to gain weight while taking this medication." "While taking this medication, I will experience flushing of my skin.": "I should take this medication with a meal." -take metformin with or immediately following meals to improve absorption and to minimize gastrointestinal distress. Rationale -Metformin decreases the amount of glucose produced in the liver and increases tissue sensitivity to insulin -Typically, clients lose weight when beginning to take metformin due to nausea and vomiting. 7. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). A new bag is not available when the current infusion is nearly completed. Which of the following actions should the nurse take? Keep the line open with 0.9% sodium chloride until the new bag arrives. Administer dextrose 10% in water until the new bag arrives. Flush the line and cap the port until the new bag arrives. Decrease the infusion rate until the new bag arrives.: Administer dextrose 10% in water until the new bag arrives. -TPN solutions have a high concentration of dextrose. Therefore, if a TPN solution is temporarily unavailable, the nurse should administer dextrose 10% or 20% in water to avoid a precipitous drop in the client's blood glucose level. 8. A nurse in a community clinic is caring for a client who reports an increase in the frequency of migraine headaches. To help reduce the risk for migraine headaches, which of the following foods should the nurse recommend the client avoid? Shellfish Aged cheese Peppermint candy Enriched pasta: Aged cheese 9. A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. Which of the following prescribed medications should the nurse instruct the client to withhold for 48 hr prior to cardioversion? Enoxaparin Metformin Diazepam Digoxin: Digoxin 10. A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a productive cough. Which of the following actions should the nurse take first? Obtain a sputum sample. Administer antipyretics. Provide hand hygiene education. Initiate airborne precautions.: Initiate airborne precautions. -exhibiting manifestations of tuberculosis. The greatest risk in this client situation is for other people in the facility to acquire an airborne disease from this client. Therefore, the first action the nurse should take is to initiate airborne precautions. 11. A nurse is caring for a client who has a stage 111 pressure injury. Which of the following findings contributes to delayed wound healing? WBC count 6,000/mm3 BMI 24 Urine output 25 mL/hr Albumin 4 g/dL: Urine output 25 mL/hr -Urinary output reflects fluid status. Inadequate urine output can indicate dehydration, which can delay wound healing. Rationale -well-managed pain level enhances a client's willingness to increase mobility. -BMI less than 18.5 are considered at risk for complications, such as poor wound healing. (24 is within normal limits) 12. A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first? -Obtain ABGs -Administer Propofol to the client. -Instruct the client to allow the machine to breathe for them. -Disconnect the machine and manually ventilate the client.: Instruct the client to allow the machine to breathe for them. -should first use the least restrictive intervention. Therefore, the first action the nurse should take is to provide verbal instructions and emotional support to help the client relax and allow the ventilator to work. 13. A nurse is caring for a client who has hepatic encephalopathy that is being treated withy lactulose. The client is experiencing excessive stools. Which of the following findings is an adverse effect of this medication? Hypokalemia Hypercalcemia Gastrointestinal bleeding Confusion: Hypokalemia 14. A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit? Heart rate 110/min Blood pressure 138/90 mm Hg Urine specific gravity 1.020 BUN 15 mg/dL: Heart rate 110/min [Show Less]

ATIRN FUNDAMENTALS ONLINE PRACTICE 2023/2024 WITH NGN 117QUESTIONS AND ANSWERS LATEST UPDATE 2023/2

A nurse is admitting a client who has an abdominal wound with a large amount of purple tissue drainage. Which of the following types of transmission precau... [Show More] tions should the nurse initiate? Protective environment Airborne precautions Droplet precautions Contact precautions - CORRECT RESPONSE✔✔Contact precautions A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take? -Discuss the risk factors for colon cancer. -Focus teaching on what the client will need to do in the future to manage his illness. -Provide the client with written information about the phases of loss & grief. -Reassure the client that this is an expected response to grief. - CORRECT RESPONSE✔✔-Reassure the client that this is an expected response to grief. A nurse is caring for a client who is postoperative following a knee arthroplasty & requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take? -Assist the client into a prone position -Place a sleeve over the top of each leg with the opening at the knee -Make sure two finger can fit under the sleeves -Set ankle pressure at 65 mmHg - CORRECT RESPONSE✔✔-Make sure two finger can fit under the sleeves A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressings should the nurse use? Alienate Gauze Transparent Hydrocolloid - CORRECT RESPONSE✔✔Hydrocolloid A nurse is preparing an education program for the staff about advocacy. Which of the following information should the nurse include? -Advocacy ensures clients' safety, health, & rights. -Advocacy series that nurses are able to explain their own actions. -Advocacy ensures that nurses follow through on their promises to clients. -Advocacy ensures fairness in client care delivery and use of resources. - CORRECT RESPONSE✔✔Advocacy ensures clients' safety, health, & rights. A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? -Verify the client's name on their identification bracelet with the medication administration record -Call the pharmacy to determine whether the client's medications are available -Compare the clients home medications with the provider's prescriptions -Place the client's home medication bottles in a secure location - CORRECT RESPONSE✔✔Compare the clients home medications with the provider's prescriptions A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety need? (Select all that apply) -Lacrimal apparatus -Pupil clarity -Appearance of bulbar conjunctivae -Visual fields -Visual acuity - CORRECT RESPONSE✔✔Pupil clarity Visual fields Visual acuity A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching? -"I can place an extension cord across my living room to plug in my television." -"I will hire someone to trim the tree that hangs low over the stairs of my front porch." -"I will place my alarm clock on my bedroom dresser across the room." -"I will replace the old throw rug in my kitchen with a new one." - CORRECT RESPONSE✔✔-"I will hire someone to trim the tree that hangs low over the stairs of my front porch." A nurse is reviewing a client's fluid & electrolyte status. Which of the following findings should the nurse report to the provider? BUN 15 mg/dL Creatinine 0.8 mg/dL Sodium 143 mEq/L Potassium 5.4 mEq/L - CORRECT RESPONSE✔✔Potassium 5.4 mEq/L nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. the nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min & to report back in 1 hr. Which of the following actions should the nurse take next? -Document the providers statement in the medical record -Complete an incident report -Consult the facility's risk manager -Notify the nursing manager - CORRECT RESPONSE✔✔Notify the nursing manager The client states: "I am unable to eat anything without vomiting" select 3 tasks the nurse should delegate -document the client's vitals -measure the client's intake and output -transfer the client from wheelchair to bed -insert an NG tube for the client -collect data about the client's pain level. - CORRECT RESPONSE✔✔-document the client's vitals -measure the clients intake and output -transfer the client from wheelchair to bed A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? -Increase hematocrit -Increase respiratory rate -Decrease heart rate -Decrease in capillary refill time - CORRECT RESPONSE✔✔-Decrease heart rate A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? -Combine client care tasks when caring for multiple clients -Wait until the end of the shift to document client care -Use the planning step of the nursing process to prioritize client care delivery -Allow for interruptions in tasks to discuss client care issues with colleagues - CORRECT RESPONSE✔✔Use the planning step of the nursing process to prioritize client care delivery A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress? Role ambiguity Sick role Role overload Role conflict - CORRECT RESPONSE✔✔Role overload The client reported fever, chills, cough, and night sweats for the past 2 weeks the nurse is placing the client on isolation precautions. which of the following interventions should the nurse include? -wear an N95 mask when caring for the client -place a container for soiled linens inside the client's room -place the client in a negative airflow room -remove the mask after exiting the client's room -wear a sterile, water-resistant gown if within 3 feet of the client. - CORRECT RESPONSE✔✔-wear an N95 mask when caring for the client -place a container for soiled linens inside the clients room -place the client in a negative airflow room -remove mask after exiting the clients room [Show Less]

ATIRN COMPREHENSIVE EXAM WITH NGN 180 QUESTIONS ALONG WITH RATIONALE FOR CORRECT ANSWERS 2023/2024

A nurse is caring for a client who has a fractured femur and has a fiberglass leg cylinder cast for 24 hours. What is the priority assessment finding? - CO... [Show More] RRECT ANSWERS the client's heel is reddened and tender because this could be an early indicator of a pressure injury and the pt is at high risk for pressure injuries why are the other findings not priorities? - cast gets wet: fiberglass casts are waterproof - increase pain when leg is lowered below level of the heart: the leg should be elevated to help reduce edema and pain but preventing pressure injuries is priority - the pt reports itching under the cast: the pt is at risk for dry and itchy skin so the nurse should offer a hair dryer to blow COOL air on the skin, but preventing pressure injury is priority A nurse is providing client education to a postpartum client who has decided to bottle feed the newborn. Which of the following instructions should the nurse include in the teaching to help prevent the discomfort of engorgement? - CORRECT ANSWERS place ice packs on the breasts for 15 min several times per day because this helps reduce swelling and relieve pain why are the other instructions incorrect? - allow the newborn to breastfeed temporarily: avoid nipple stimulation because this will increase milk production - relieve pressure by expressing milk daily: avoid expressing milk to prevent further milk production - sleep with a loose fitting bra to prevent nipple stimulation: wear a tight fighting, supportive bra or a breast binder to decrease discomfort caused by engorgement A nurse is preparing to insert an indwelling urinary catheter for a client. The nurse should assess the client for which of the following conditions prior to starting the procedure? - CORRECT ANSWERS latex allergy because of the risk of an allergic reaction to the catheter why are the other answers incorrect? - ketonuria: this is the presence of ketones in the urine and occurs - fecal impaction or tachycardia: these conditions do not pose a safety risk during the insertion of an indwelling catheter ketonuria - CORRECT ANSWERS this is the presence of ketones in the urine and occurs due to fatty acid catabolism caused by hyperglycemia, starvation, high-protein diets, and alcohol use disorder sickle cell anemia - CORRECT ANSWERS a genetic disorder that causes abnormal hemoglobin, resulting in some red blood cells assuming an abnormal sickle shape vaso-occlusive crisis - CORRECT ANSWERS Ischemia and pain caused by sickle-shaped red blood cells that obstruct blood flow to a portion of the body, for example an organ becomes restricted, causing pain, ischemia and often organ damage other s/s: visual disturbance, hematuria, painful swelling extremities, fever, tachycardia, PAIN A nurse is assessing a client who has sickle cell anemia. The nurse should identify which of the following findings as a manifestation of vase-occlusive crisis? - CORRECT ANSWERS hematuria because it is a manifestation that results from ischemia of the kidneys what answers are not signs of vast-occlusive crisis? - diminished reflexes, hyperglycemia, hearing loss what are other signs of vast-occlusive crisis? painful swelling of the hands and feet, visual disturbances A nurse is assessing a client during the immediate postpartum period. Which of the following findings requires immediate intervention by the nurse? - CORRECT ANSWERS boggy uterus because this can indicate uterine hemorrhage and this is URGENT why do the other findings not require immediate intervention by the nurse? - intermittent cramping, moderate lochia rubra, and perineal edema are all NONURGENT and are expected findings - excessive lochia rubra and large clots should be reported to the provider - intermittent cramping/afterpainscan be eased by heat and lying prone - perineal edema occurs due to the excessive amount of pressure experienced during vaginal birth, the nurse can offer ice or sitz baths what does the nurse do if the pt has a "boggy uterus" during the immediate postpartum period? - CORRECT ANSWERS this is URGENT and can indicate a uterine hemorrhage, so the nurse should IMMEDIATELY intervene to stimulate uterine contractions and prevent blood loss, because if the uterus becomes relaxed during the postpartum period the client will rapidly lose blood because no permanent thrombi have formed at the placenta what is lochia rubra? - CORRECT ANSWERS the first stage of lochia, lasts 3-4 days, dark or bright red blood, flow is similar to a heavy period, small blood clots and mild, period-like cramping are normal A nurse is assessing a client who has antisocial personality disorder. Which of the following manifestations should the nurse expect? - CORRECT ANSWERS lack of remorse [Show Less]

NGN ATI RN Comprehensive HESI EXIT Q & As BEST EXAM SOLUTION LATEST UPDATE 2024 GRADED A+

• A school nurse is teaching a parent about absent seizures. Which of thefollowing information should the nurse include? A. “This type of seizure ca... [Show More] n be mistaken for daydreaming.” B. “This type of seizure lasts 30 to 60 seconds.” C. “The child usually has an aura prior to onset.” D. “This type of seizure has a gradual onset.” • A nurse is planning care for a client who has cancer and is about to receive low dose brachytherapy via a vaginal implant applicator. Which ofthe following interventions should the nurse include in the plan of care? A. Removal of vaginal packing B. Insertion of an indwelling urinary catheter C. Ambulation four times daily D. Maintenance of NPO status until therapy is complete • A nurse is caring for a client who wears glasses. Which of the followingactions should the nurse take? E. Store the glasses in a labeled case. F. Clean the glasses with hot water. G. Clean the glasses with a paper towel. H. Store the glasses on the bedside table. • A nurse is teaching about preventative measures to a female client whohas chronic urinary tract infections. Which of the following interventions should the nurse include in the teaching? A. “Drink 2 liters of warm water per day”. B. “Empty your bladder every 6 weeks.”. C. “Soak in a warm bath everyday”. D. “Take an oral estrogen tablet”. • A nurse is receiving change-of-shift report for a group of clients. Which ofthe following clients should the nurse plan to assess first? A. A client who has sinus arrhythmia and is receiving monitoring B. A client who has a hip fracture and a new onset of tachypnea C. A client who has epidural analgesia and weakness in the lowerextremities D. A client who has diabetes and a hemoglobin A1C of 6.8% • A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include? A. Consume food high in bran fiber B. Increase intake of milk products C. Sweeten foods with fructose corn syrup D. Increase foods high in gluten • A nurse is caring for a 1-day-old newborns who has jaundice and is receiving phototherapy. Which of the following actions should the nursetake? A. the infant 30 ml (1 oz) glucose water every 2 hr. B. Keep the infants head covered with a cap. C. Ensure that the newborn wears a diaper. D. Apply lotion to the newborn every 4 hr. • a nurse is teaching a group of newly licensed nurses about client advocacy. Which of the following statements by a newly licensed nurseindicates an understanding of the teaching? A. “(Unable to read) I feel to be in his best health care decision” B. “I will intervene if there is conflict between a client and his provider” C. “I should not advocate for a client unless he is able to ask me himself” D. “I will inform a client that his family should help make his health caredecisions.” • A nurse is preparing to reposition a client who had a stroke. Which of thefollowing actions should the nurse take? A. Raise the side rails on both sides of the client’s bed duringrepositioning. B. Reposition the client without assistive devices. C. Discuss the client’s preferences for determining a reposition schedule. D. Evaluate the client’s ability to help with repositioning. • A • A nurse is caring for an infant who has coaction of the aorta. Which of thefollowing should the nurse identify as an expected finding? A. Weak femoral pulses B. Frequent nosebleeds C. Upper extremity hypotension D. Increased intracranial pressure\ • a nurse is auscultating for crackles on a client who has pneumonia.Which of the following anterior chest wall locations should the nurse auscultate? • A nurse is assisting with the development of an informed document for participation in a research study. Which of the following information shouldthe nurse include? A. A statement that participants can leave the study at will. B. An assignment of the participant to either the experimental or controlgroup. C. A list of the clients participating in the study. D. A description of the framework the researchers will use to evaluate thedata. • A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include? A. Excessive sweating B. Increased urinary frequency C. Dry cough D. Metallic taste in mouth • A nurse is caring for a client who has a new temporary synchronous pacemaker. Which of the following should the nurse report to the provider? A. The client’s pulse oximetry level is 96%. B. (Unable to read) C. The client develops hiccups. D. The ECG shows pacing spikes after the QRS complex. • A nurse is preparing discharge information for a client who has type 2 diabetes mellitus. Which of the following resources should the nurse provideto the client? A. Personal blogs about managing the adverse effects of diabetesmedications B. Food label recommendations from the Institute of Medicine C. Diabetes medication information from the Physicians’ Desk Reference D. Food exchange lists for meal planning from the American DiabetesAssociation [Show Less]

NGN 2024 latest update Adult Medical Surgical ATI Proctored Exam

Question: 90 of 90 CORRECT FLAG • Time Remaining: 00:38:42 • Pause Remaining: 00:05:00 PAUSE A nurse is caring for a clie... [Show More] nt who has atopic dermatitis and a prescription for triamcinolone ointment. The nurse should assess the client to monitor for which of the following adverse effects? Increased pigmentation Topical glucocorticoid therapy can cause the adverse effect of hypopigmentation. Localized hair loss Long-term glucocorticoid therapy can cause hypertrichosis, or excessive hair growth, especially on the facial area. Thinning of the skin MYANSWER Thinning of the skin and delayed healing are adverse effects of topical glucocorticoid preparations. The client should only apply the ointment to dry patches of the skin because topical steroids can cause atrophy of the dermis and epidermis, which can result in thinning of the skin. Increased sensitivity to the sun The nurse should instruct the client to avoid excessive sun exposure when taking topical fluticasone; however, triamcinolone ointment does not cause photosensitivity. • RN VATI Adult Medical Surgical 2019 CLOSE Q ue stion 89 loade drationals prov i de d Question: 89 of 90 CORRECT • Time Remaining: 00:37:45 FLAG • Pause Remaining: 00:05:00 PAUSE A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse identify as a manifestation of left-sided heart failure? Dependent edema The nurse should identify that dependent edema is a manifestation of right-sided heart failure due to right ventricular failure and fluid retention from pressure building up in the venous system. Jugular distention The nurse should identify that jugular vein distention is a manifestation of right-sided heart failure due to right ventricular failure and fluid retention from pressure building up in the venous system. Weight gain The nurse should identify that weight gain is a manifestation of right-sided heart failure due to right ventricular failure and fluid retention from pressure building up in the venous system. MYANSWER The nurse should identify that frothy sputum, dyspnea, and wheezing are manifestations of left-sided heart failure. Treatment includes fluid restriction and diuretics to decrease preload and reduce pulmonary congestion. Pink-tinged frothy sputum can be an early indication of pulmonary edema and can be life-threatening. Therefore, the nurse should notify the provider immediately. • RN VATI Adult Medical Surgical 2019 CLOSE Q ue stion 88 loade drationals prov i de d Question: 88 of 90 CORRECT • Time Remaining: 00:37:30 • Pause Remaining: 00:05:00 PAUSE FLAG A nurse is caring for a client who is experiencing anxiety as well as numbness and tingling of the lips and fingers. The client's ABGs are: pH 7.48, PCO2 30 mm Hg, HCO3- 24 mEq/L, PaO2 85 mm Hg. Which of the following acid-base imbalances should the nurse identify that the client is experiencing? Respiratory alkalosis MYANSWER This pH is alkaline (increased) and the PCO2 is decreased, representing alveolar hyperventilation and resultant respiratory alkalosis. Respiratory acidosis This pH is alkaline (increased) and the PCO2 is decreased. A decreased pH and an increased PCO2 indicate respiratory acidosis. Metabolic alkalosis This HCO3- 24 mEq/L is within the expected range of 21 to 28 mEq/L and the pH is alkaline (increased). An increased pH and HCO3- indicate metabolic alkalosis. Metabolic acidosis This HCO3- 24 mEq/L is within the expected range of 21 to 28 mEq/L and the pH is alkaline (increased). A decreased pH and HCO3- indicate metabolic acidosis. • RN VATI Adult Medical Surgical 2019 CLOSE Q ue stion 87 loade drationals prov i de d Question: 87 of 90 CORRECT FLAG • Time Remaining: 00:37:22 • Pause Remaining: 00:05:00 PAUSE A nurse is assessing a client who has Cushing's syndrome. Which of the following findings should the nurse expect? Vitiligo Vitiligo is the loss of pigment from areas of a client's skin, causing irregular, white patches. Vitiligo is a manifestation of adrenal-gland hypofunction. Osteoporosis MYANSWER Osteoporosis is a common finding with Cushing's syndrome. Bones become thinner as a result of mineral loss and nitrogen depletion, and the risk for fractures increases. Myxedema A client who has hypothyroidism can develop myxedema that causes mucinous cellular edema around the eyes, across the upper back, and in the hands and feet. Heat intolerance A client who has hyperthyroidism can develop heat intolerance, along with an increase in sweating. • RN VATI Adult Medical Surgical 2019 CLOSE Q ue stion 86 loade drationals prov i de d Question: 86 of 90 CORRECT FLAG • Time Remaining: 00:37:13 • Pause Remaining: 00:05:00 PAUSE A nurse is inspecting the skin of a client who has basal cell carcinoma. The nurse should identify which of the following lesion characteristics on the client's skin? A pearly, waxy nodule MYANSWER A client who has basal cell carcinoma has a nodular lesion with well-defined borders and a pearly or waxy appearance, resulting from overexposure to the sun, especially on the face, head, and neck. An irregular border on a variegated-colored lesion A client who has melanoma has a lesion with irregular borders and variegated colors of red, white, and blue, most often on the upper back or lower legs. A firm, nodular, crusty, or ulcerated lesion A client who has squamous cell carcinoma has a firm, nodular, and crusty lesion with an ulcerated center, resulting from sun exposure, chronic irritation, burns, or irradiation to the skin. A weeping vesicle A client who has herpes zoster has weeping, blister-type lesions. • RN VATI Adult Medical Surgical 2019 CLOSE Q ue stion 85 loade drationals prov i de d Question: 85 of 90 CORRECT FLAG • Time Remaining: 00:37:02 • Pause Remaining: 00:05:00 PAUSE A nurse is assessing a client who has hypocalcemia. In which of the following areas should the nurse tap on the client's face to detect the presence of Chvostek's sign? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.) A is correct. The nurse should tap the client's cheek just in front of the ear and below the zygomatic arch. The client who has hypocalcemia will display a Chvostek's sign, which is a twitching of the facial muscle. B is incorrect. The nurse should apply upward pressure at the supraorbital ridge, below the eyebrow, to assess for tenderness and inflammation of the frontal sinuses. C is incorrect. The nurse should palpate the jaw and mastoid muscle of a client who has temporomandibular joint dysfunction. This can be caused by misaligned teeth, arthritis, or grinding of the teeth. With palpation, the nurse might feel a click, pop, or grating sensation when the client opens or closes the jaw. • RN VATI Adult Medical Surgical 2019 CLOSE Q ue stion 84 loade drationals prov i de d Question: 84 of 90 CORRECT FLAG • Time Remaining: 00:36:55 • Pause Remaining: 00:05:00 PAUSE A nurse in an emergency department is assessing a client who is overusing prescribed diuretics and has a sodium level of 127 mEq/L. Which of the following laboratory findings should the nurse expect? High lipase A high lipase level is associated with pancreatic dysfunction or renal failure and is not an expected finding with hyponatremia or dehydration. MYANSWER A client who has hyponatremia as a result of diuretic overuse has a low urine specific gravity. The increased excretion of water alters the ratio of particulate matter, which affects the specific gravity. Low hemoglobin A client who is dehydrated as a result of diuretic overuse can have an elevated hemoglobin level because of the difference in ratio between intravascular fluid and blood cells. High creatine kinase-MB (CK-MB) An elevated CK-MB level indicates a myocardial infarction and is not an expected finding with hyponatremia. [Show Less]

ATIRN ADULT MED-SURG PROCTORED EXAM GUIDE QUESTIONS AND ANSWERS WITH NGN (LATEST VERSION 2023/2024)

A home health nurse is caring for a client who has COPD. The client tells the nurse that he becomes short of breath while eating despite the use of home ox... [Show More] ygen. What instructions should the nurse include? - ansDrink beverages at the end of meals A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. What statement by the client indicates that they are adhering to the nurse's instructions? - ans"I don't cross my legs anymore". A nurse enters the room of a client whose transfusion of packed RBCs was initiated 15 min ago by the RN. The client reports dyspnea and urticaria. What action should the nurse perform first? - ansStop the infusion A nurse in an orthopedic clinic is reinforcing teaching with a client who has osteoarthritis. What instructions should the nurse include to promote comfort? - ansSleep on a firm mattress A nurse is admitting a client who is suspected having active tuberculosis (TB). What action should should the nurse take first? - ansInstitute airborne precautions A nurse is assisting in the care of a client who has manifestations of sepsis. What provider prescriptions should the nurse implement first? - ansInitiate oxygen at 4 L/min via nasal cannula A nurse is assisting in the plan of care for a client who has a recent left hemispheric stroke. What action should the nurse include in the plan? - ansUse simple verbal cues when directing tasks A nurse is assisting with an educational program for clients who have newly diagnosed with diabetes mellitus. What instruction should the nurse include in the program regarding insulin? - ansOpened insulin can be stored on a cool countertop away from light A nurse is caring for a client following a gastrectomy. What action should the nurse take to decrease episodes of dumping syndrome? - ansPlace the client in the supine position after meals A nurse is caring for a client who has a methicillin-resistant Staphlococcus aureus (MRSA) infections in a surgical wound. What information should the nurse plan to share with visitors? - ansVisitors must don a gown & gloves prior to entering the client's room. A nurse is caring for a client who has a new cast on her left forearm and report severe pain in the affected arm with numbness in the fingers. The nurse finds the skin is pale and cold with sluggish capillary refill. What fracture complication should the nurse suspect? - ansCompartment syndrome A nurse is caring for a client who has a prescription for digoxin 0.25mg PO daily. While taking the client's apical pulse, the nurse notes a rate of 58/ min. What action should the nurse take? - ansWithhold the dose A nurse is caring for a client who has an intestinal obstruction & reports a new onset of nausea. The client has an NG tube set at low intermittent suction & is receiving continuous IV infusion of 0.9% sodium chloride. What action should the nurse take first? - ansCheck for kinks in the NG tube A nurse is caring for a client who has dementia due to Alzheimer's disease. What action should the nurse take to reduce the client's confusion? - ansEncourage reminiscence of past experiences A nurse is caring for a client who has meningococal pneumonia. Which of the following personal protective equipment should the nurse use? - ansMask (this disease requires droplet precautions) A nurse is caring for a client who has terminal pancreatic cancer. The client states, "I don't think I can go on any longer." What response should the nurse make? - ans"Tell me more about the way you are feeling." A nurse is caring for a client who is 1 day post operative following a hip arthroplasty. The client is exhibiting hypotension, tachycardia, & tacky-nearly. The nurse should recognize these findings as what complication? - ansPulmonary Embolism A nurse is caring for a client who is 24hr postoperative following abdominal surgery & has an NG tube. What action should the nurse plan to take to decrease the risk of postoperative complications? - ansEncourage the client to use an incentive spirometer every hour while awake A nurse is caring for a client who is 24hr postoperative following an abdominal surgery. What finding requires immediate attention from the nurse? - ansOxygen saturation of 88% A nurse is caring for a client who is in Buck's traction. What intervention should the nurse perform to reduce skin breakdown? - ansKeep the skin dry and free of perspiration A nurse is caring for a client who is post operative following a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigation. The nurse notes decreased output from the urethral catheter. What prescription should the nurse expect the provider to order? - ansIrrigate the urethral catheter with 0.9% sodium chloride A nurse is caring for a client who reports shortness of breath and has an oxygen saturation of 90%. What action should the nurse take? - ansAdminister oxygen via nasal cannula A nurse is caring for a female client who is being treated for dehydration due to nausea & vomiting. What finding should the nurse report to the provider? - ansHeart rate 120/ min A nurse is caring for four clients. What conditions should the nurse identify as a risk for developing vascular disease? - ansDiabetes mellitus A nurse is collecting data from a client who has chronic kidney disease with hyperkalemia. What finding should the nurse expect related to hyperkalemia? - ansBradycardia A nurse is collecting data from a client who has hypokalemia. What finding should the nurse identify as the priority? - ansDysrhythmia A nurse is collecting data from a client who has hypothyroidism. What manifestation should the nurse expect? - ansBradycardia A nurse is contributing to the plan of care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infections and is on contract isolation precautions. What action should the nurse take? - ansHave a designated stethoscope in the client's room A nurse is contributing to the plan of care for a client who has just transferred to the medical-surgical unit from PACU following a right total knee arthroplasty. What interventions should the nurse include in the plan? - ansAssist the client to change position every 2hr [Show Less]

NGN ATI RN MATERNAL NEWBORN PROCTORED EXAM TESTBANK ACTUAL QUESTIONS WITH VERIFIED SOLUTIONS/A+ GRA

1. A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the following findings support this dia... [Show More] gnosis? A. Painless red vaginal bleeding Rationale: Placenta previa is a condition of pregnancy when the placenta implants in the lower part of the uterus, partly or completely obstructing the cervical os (outlet to the vagina). Bright red, painless vaginal bleeding occurs in the second and third trimester. B. Increasing abdominal pain with a nonrelaxed uterus Rationale: Abruptio placenta is separation of the placenta from the site of uterine implantation before delivery of the fetus. When the placenta separates prematurely, there is internal bleeding, which is painful, and the uterus is nonrelaxed or becomes rigid as the separation advances. C. Abdominal pain with scant red vaginal bleeding Rationale: Placenta previa involves minimal to severe bright red vaginal bleeding in the absence of abdominal pain. D. Intermittent abdominal pain following passage of bloody mucus Rationale: Intermittent abdominal pain following passage of bloody mucus is a description of normal labor. The passage of bloody mucus represents the loss of the cervical mucous plug, also referred to as the "bloody show." 2. A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take? A. Document the findings and continue to monitor the client. Rationale: These are expected findings. At 1 hr postpartum, lochia rubra should be intermittent and associated with uterine contractions. The volume of lochia resembles that of a heavy menstrual period. Small clots are common. The nurse should document the findings and continue to monitor the client. B. Notify the client‟s provider. Rationale: These are expected findings, so there is no need to notify the provider. C. Increase the frequency of fundal massage. Rationale: These are expected findings and the fundus is already firm. Increasing the frequency of fundal massage is not indicated at this time. D. Encourage the client to empty her bladder. Rationale: These are expected findings, and the fundus is firm at the midline. If the fundus was deviated, this would be an indication of a distended bladder and the client should be encouraged to void to prevent uterine atony. 3. A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action? A. Administer vitamin K. Rationale: Administration of vitamin K is important, but it can be delayed until the newborn is held by the mother and is breastfed. There is another, more important nursing action. B. Dry the skin. Rationale: The newborn should be thoroughly dried, covered with a warm blanket, placed on the mother‟s abdomen, and a cap applied to the newborn‟s head to prevent cold stress. The newborn responds to the cooler environment by increasing his respiratory rate, which can lead to respiratory distress. Based on Maslow‟s hierarchy of needs, this is the most important nursing action after securing the airway. C. Administer eye prophylaxis. Rationale: Administration of eye prophylaxis should occur within the first hour after birth. There is another, more important nursing action. D. Place an identification bracelet. Rationale: Correct identification of the newborn is important, but it can be delayed, as long as it is completed prior to the mother and newborn leaving the delivery room. There is another, more important nursing action. 4. A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make? A. "It's a minor inconvenience, which you should ignore." Rationale: This is a nontherapeutic response that disregards the client‟s concern and offers unwarranted reassurance. B. "In most cases it only lasts until the 12th week, but it will continue if you have poor bladder tone." Rationale: The presence or absence of bladder tone has no bearing on urinary frequency during pregnancy. C. "There is no way to predict how long it will last in each individual client." Rationale: This is a nontherapeutic response that does not provide appropriate information to the client. D. "It occurs during the first trimester and near the end of the pregnancy." Rationale: Urinary frequency is due to increased bladder sensitivity during the first trimester and recurs near the end of the pregnancy as the enlarging uterus places pressure on the bladder. A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client's blood work, the nurse notices she does not have immunity to rubella. Which of the following times should the nurse understand is recommended for rubella immunization? E. Shortly after giving birth Rationale: The rubella immunization should be offered to the client following birth, preferably prior to discharge from the hospital. This prevents the client from contracting rubella during the current or subsequent pregnancies, which would put her fetus at risk for rubella syndrome. F. In the third trimester Rationale: Because the rubella vaccine contains a live virus, immunizing the client at this point in pregnancy would put her fetus at risk for developing rubella syndrome. G. Immediately Rationale: Because the rubella vaccine contains a live virus, immunizing the client during the first trimester would put the fetus at risk for developing a severe manifestations of rubella syndrome. H. During her next attempt to get pregnant Rationale: Rubella immunization must be given at least 28 days prior to pregnancy to assure that the developing fetus is not exposed to the virus and put at risk for rubella syndrome. 5. A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn? A. Clear the respiratory tract. Rationale: Clearing the airway of the infant is the first action the nurse should take immediately following delivery. B. Dry the infant off and cover the head. Rationale: Drying the infant and covering the head should be done shortly after the delivery, but it is not the first action the nurse should take. C. Stimulate the infant to cry. Rationale: Stimulating the infant to cry should be done shortly after the delivery, but it is not the first action the nurse should take. D. Cut the umbilical cord. Rationale: Cutting the umbilical cord should be done shortly after the delivery, but it is not the first action the nurse should take. 6. A nurse in a family planning clinic is caring for a 17-year-old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make? A. "What part of the exam makes you most nervous?" Rationale: This therapeutic response recognizes the client's feelings. It also uses the therapeutic technique of clarification to encourage the client to tell the nurse more about her concerns. B. "Don't worry, I will be with you during the exam." Rationale: This closed-ended nontherapeutic response discounts the client's feelings and does not encourage further discussion. C. "All you need to do is relax." Rationale: This closed-ended nontherapeutic response does not address the client's concerns and does not encourage further discussion. It blocks communication by using a cliché and false reassurance. D. "A pelvic exam is required if you want birth control pills." Rationale: This statement fails to address the client‟s feelings that she shared with the nurse. It blocks communication and does not encourage further discussion. 7. A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord? A. Two veins and one artery Rationale: This is not the correct combination of vessels. B. One artery and one vein Rationale: This is not the correct combination of vessels. C. Two arteries and one vein Rationale: The vein carried the oxygenated, nutrient-rich blood from the placenta to the fetus, and the two arteries returned the blood to the placenta. D. Two arteries and two veins Rationale: This is not the correct combination of vessels. [Show Less]

ATI ADULT MED SURG ATI RN ADULT MEDICAL SURGICAL (NGN) 2023/2024 QUESTIONS WITH VERIFIED ANSWERS/A+

ATI ADULT MED SURG /ATI RN ADULT MEDICAL SURGICAL (NGN) 2023 QUESTIONS WITH VERIFIED ANSWERS/A+ GRADE ASSURED \ • "I will need to take antibiot... [Show More] ics for 1 year." – INCORRECT o A client who has severe stage I Lyme disease will be prescribed a 30-day course of antibiotics. The nurse should emphasize to the client that, like with other types of infection, the full course of antibiotics should be completed. • "My partner will need to take an antiviral medication." – INCORRECT o Lyme disease is a vector-borne illness that is treated with antibiotics. Other vector-borne illnesses, such as West Nile Virus, are treated with antiviral medications. Lyme disease is not transmitted to others via human contact. • "My joints ache because I have Lyme disease." – CORRECT o Lyme disease is a vector-borne illness transmitted by the deer tick. The disease course occurs in three stages beginning with joint and muscle pain in stage I. If left untreated, these symptoms continue throughout stage I and, by stage Ill, become chronic. Other chronic complications include memory problems and fatigue • "I bruise easily because I have Lyme disease. – INCORRECT o Lyme disease is an infectious disease that affects the body systemically, involving the neurologic, musculoskeletal, and cardiac systems. Cardiac manifestations include carditis and dysrhythmias. However, a client who has stage Il Lyme disease does not typically experience bruising. • Extremity cool upon palpation – CORRECT o The nurse should report indicators of reduced circulation, such as pallor, cool temperature, or paresthesia of the client's extremity. These findings can indicate that the client is at risk for developing acute compartment syndrome. • Serosanguineous drainage on the dressing – INCORRECT o Serosanguineous, or blood-tinged, drainage on the dressing is an expected finding following surgery. Serosanguineous drainage is present the first few days following surgery as the wound heals. • Capillary refill of 2 seconds – INCORRECT o A capillary refill of 2 seconds is within the expected reference range and indicates the client has adequate arterial blood flow. A delay in capillary refill can indicate an earl manifestation of acute compartment syndrome. • Client report of discomfort when moving toes – INCORRECT o A report of discomfort when moving toes is an expected finding following surgery. However, a report of increased pain at the surgical site when moving can indicate an early manifestation of acute compartment syndrome. • The client starts to cough. – INCORRECT o The nurse should expect the client to cough during suctioning of a tracheostomy due to bronchial stimulation. • The client's heart rate increases. – CORRECT o Hypoxia related to suctioning can cause the client's heart rate to increase. If this occurs, the nurse should discontinue the suctioning and manually oxygenate the client with 100% oxygen. The nurse should instruct the client to take three or four deep breaths prior to suctioning to reduce the risk for hypoxia. • The client is diaphoretic. – INCORRECT o Diaphoresis is not associated with suction-induced hypoxia. However, long-term hypoxia can lead to diaphoresis. • The client's blood pressure decreases. – INCORRECT o A clients blood pressure can increase initially with hypoxia. If this occurs, the nurse should stop suctioning and manually oxygenate the client. Long-term hypoxia can lead to a decrease in blood pressure and shock • Document the client's intake and output. – INCORRECT o The nurse should document the client's intake and output to ensure adequate fluid balance. However, there is another action that the nurse should take first. • Scan the bladder with a portable ultrasound. – CORRECT o 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. • Pour warm water over the client's perineum. – INCORRECT o Pouring warm water over the client's perineum is a method for stimulating micturition. However, there is another action that the nurse should take first. • Perform a straight catheterization. – INCORRECT o Performing a straight catheterization might prove necessary. However, there is another action that the nurse should take first. [Show Less]

RN ATI COMPREHENSIVE PREDICTOR EXAM QUESTIONS AND ANSWERS LATEST UPDATE WITH NGN 2023/2024