ATI RN Adult Medical Surgical Proctored Exam
2019
A nurse is caring for a client who has hepatic encephalopathy that is being treated with
lactulose.
... [Show More] The client is experiencing excessive stools. Which of the following findings is
an adverse effect of this medication? - ANSWER-Hypokalemia
Rationale: Lactulose works by stimulating the production of excess stores to rid the
body of excess ammonia. These excessive stores can result in a hypo kalemia and
dehydration.
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? - ANSWER-Instruct
the client to allow the machine to breathe for them.
Rationale: When providing client care, the nurse should first use the least restrictive
intervention. Therefore, the first action the nurse should take is to provide verbal
instructions in emotional support to help the client relax and allow the ventilator to work.
Clients can exhibit anxiety and restlessness we're trying to "fight the ventilator."
A nurse is teaching a client who has a family history of colorectal cancer. To help
mitigate this risk, which of the following dietary alterations should the nurse
recommend? - ANSWER-Add cabbage to the diet.
Rationale: To help reduce the risk for colorectal cancer, the client should consume a
diet that is high in fiber, low in fat, and low in refined carbohydrates. Brassica
vegetables, such as cabbage, cauliflower, and broccoli, are all high in fiber.
A home health nurse is assigned to a client who was recently discharged from a
rehabilitation center after experiencing a right-hemispheric stroke. Which of the
following neurologic deficits should the nurse expect to find when assessing the client?
(Select all that apply.) - ANSWER-Visual spatial deficits, Left hemianopsia, One-sided
neglect.
Rationale: Visual spatial deficits and loss of depth perception occur secondary to a right
hemispheric stroke. Left hemianopsia, or blindness in the left half of the visual field,
occur secondary to right hemispheric stroke. One-sided neglect, or in unawareness of
the affected side, occur secondary to a right hemispheric stroke.
ATI RN Adult Medical Surgical Proctored Exam
2019
A nurse is caring for a client who has viral pneumonia. The client's pulse oximeter
readings have fluctuated between 79% and 88% for the last 30 min. Which of the
following oxygen delivery systems should the nurse initiate to provide the highest
concentration of oxygen? - ANSWER-Nonrebreather mask
Rationale: The nurse should initiate a nonrebreather mask to deliver between 80% to
95% oxygen to the client. A client who has an unstable respiratory status should receive
oxygen via non-rebreather mask.
A nurse is caring for a client who has bilateral pneumonia and an SaO2 of 85%. The
client has dyspnea with a productive cough and is using accessory muscles to breathe.
Which of the following actions should the nurse take first? - ANSWER-Place the client in
high-Fowler's position.
Rationale: the greatest risk to this client is injury from airway obstruction. Therefore,
their priority intervention the nurse should take us to move the client into high Fowlers
position. High Fowlers position facilitate long expansion and improves been elation and
gas exchange
A nurse is planning care for a client who has extensive burn injuries and is
immunocompromised. Which of the following precautions should the nurse include in
the plan of care to prevent a Pseudomonas aeruginosa infection? - ANSWER-Avoid
placing plants or flowers in the client's room.
Rationale: live plants can harbor P. Aeruginosa, And this bacterium can infect burn
moons and cause life-threatening complications. The nurse should ensure no one
brings live plants or flowers into the clients room.
An older adult client is brought to an emergency department by a family member. Which
of the following assessment findings should cause the nurse to suspect that the client
has hypertonic dehydration? - ANSWER-Urine specific gravity 1.045
Rationale: a urine specific gravity greater than 1.030 indicates a decrease in urine
volume and an increase in osmolarity, which is a manifestation of hypertonic
dehydration.
A nurse in an emergency department is reviewing the provider's prescriptions for a
client who sustained a rattlesnake bite to the lower leg. Which of the following
prescriptions should the nurse expect? - ANSWER-Administer an opioid analgesic to
the client.
Rationale: the nurse should expect a prescription for an opioid analgesic to promote
comfort following a rattlesnake bite.
A nurse is assessing a client who has had a suspected stroke. The nurse should place
the priority on which of the following findings? - ANSWER-Dysphagia
ATI RN Adult Medical Surgical Proctored Exam
2019
Rationale: dysphasia indicates that this client is at greatest risk for aspiration due to
impaired sensation and function within the oral cavity. Therefore, the nurse should place
priority on this finding.
A nurse is teaching a young adult client how to perform testicular self-examination.
Which of the following instructions should the nurse include? - ANSWER-Roll each
testicle between the thumb and fingers.
Rationale: the nurse should instruct the client to roll each testicle horizontally between
the thumbs and fingers to fill for any lumps deep in the center of the testicle.
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? - ANSWER-"I should take this medication with a meal."
Rationale: the client should take metformin with or immediately following Mills to
improve absorption and to minimize gastrointestinal distress.
A nurse is teaching a client who has venous insufficiency about self-care. Which of the
following statements should the nurse identify as an indication that the client
understands the teaching? - ANSWER-"I will wear clean graduated compression
stockings every day."
Rationale: the client should apply a clean pair of graduated compression stockings each
day and clean stalls stockings with a mild detergent and warm water by hand.
A nurse is assessing a client who has acute cholecystitis. Which of the following
findings is the nurse's priority? - ANSWER-Tachycardia
Rationale: when using the urgent versus non-urgent approach to client care, the nurse
should determine that the priority finding is tachycardia. Tachycardia is a manifestation
of biliary colic, which can lead to shock. The nurse should position the head of the
clients bed flat airport this finding immediately to the provider.
A nurse is reviewing the health record of a client wh [Show Less]