ATI PN MED SURG 2024 EXAM / ATI PN MEDICAL SURGICAL 2024 PROCTORED EXAM 180 QUESTIONS WITH DETAILED VERIFIED ANSWERS AND RATIONALES /A+ GRADE ASSURED
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A nurse is caring for a client who is 1 day postoperative following a hip arthroplasty. The client exhibiting hypotension, tachycardia, and tachypnea. The nurse should recognize that these findings indicate which of the following complications? - ....ANSWER...Pulmonary embolism.
Rationale:
Manifestations of a pulmonary embolism include hypotension, tachycardia, and tachypnea.
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Manifestations of a wound infection include fever, inflammation of the incision, and foul-smelling drainage. Hypotension, tachycardia, and tachypnea do not indicate a wound infection in a client who is 1 day postoperative.
Thrombophlebitis is the inflammation of a blood vessel, which can lead to a thrombus formation. Hypotension, tachycardia, and tachypnea do not indicate thrombophlebitis.
Paralytic ileus is the absence of bowel peristalsis, or movement. Hypotension, tachycardia, and tachypnea do not indicate a paralytic ileus.
A nurse is caring for a client who has an area indicating potential breakdown over the sacrum. Which of the following actions should the nurse take? - ....ANSWER...Minimize the time the head of the bed is elevated.
Rationale:
The nurse should minimize the time the head of the bed is elevated to reduce pressure on the sacral area.
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The nurse should collect further data before determining what type of dressing is needed. For a stage 1 pressure injury, skin preparation can be applied to preserve the integrity of the skin and prevent further direct injury. Alternatively, a dressing such as a hydrocolloid or transparent dressing can be applied. However, gauze dressings are not used in the treatment of a stage 1 pressure injury.
The nurse should not massage nor apply moisturizing lotion to an area indicating potential breakdown because it can cause further skin injury.
The nurse should not place a donut-shaped cushion under the client's sacral area because it can contribute to the development of a pressure injury.
A nurse is reinforcing teaching with an adolescent client regarding testicular self examination. Which of the following statements by the client demonstrates an understanding of the teaching? - ....ANSWER..."I understand that testicular cancer is typically painless."
Rationale:
Clients should report a lump that is not painful because testicular cancer is typically painless.
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Clients should perform a testicular self-examination after a warm shower. Clients should perform a testicular self-examination monthly.
Clients should report pea-sized lumps in the testes to a provider.
A nurse is preparing intermittent urinary catheterization for a female client who has been unable to void following surgery 6 hr ago. Which of the following catheters should the nurse use to perfrom this procedure? - ....ANSWER...Choice B (A purple tip tube )
Rationale: This is an intermittent straight catheter and is the correct catheter for the nurse to use.
A nurse is collecting data from a client who has hypothyroidism. Which of the following manifestations should the nurse anticipate? - ....ANSWER...Bradycardia
Rationale:
The nurse should identify that bradycardia is a manifestation of hypothyroidism that is caused by a decrease in the client's metabolic rate.
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Blurred vision is a manifestation of hyperthyroidism.
The nurse should identify that insomnia is a manifestation of hyperthyroidism that is caused by an increase in the client's metabolic rate.
The nurse should identify that weight loss is a manifestation of hyperthyroidism caused by an increase in the client's metabolic rate.
A home health nurse is reinforcing teaching about preventing asthma attacks with a client who has asthma. Which of the following instructions should the nurse include in the teaching? - ....ANSWER..."Do not allow visitors to smoke cigarettes in your home."
Rationale:
The nurse should inform the client that cigarette smoke is a common allergen that can increase the risk for triggering an asthma attack. Therefore, the client should not allow anyone to smoke cigarettes in their home.
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The nurse should inform the client that carpet can hold mites and dust, which increases the risk for triggering an asthma attack.
The nurse should inform the client that breathing cold air can cause bronchial constriction, which increases the risk for triggering an asthma attack.
The nurse should inform the client that opening their windows during spring can increase their exposure to environmental allergens, which increases the risk for triggering an asthma attack.
A nurse is caring for a client who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days ago. Which of the following actions should the nurse take? - ....ANSWER...Perform pin site care daily.
Rationale:
The nurse should perform pin site care daily with chlorhexidine solution or use a solution according to facility protocol. The nurse should also monitor the pin sites for manifestations of infection.
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The nurse should ensure the client has an overbed trapeze to aid in lifting the upper body off the bed when necessary and to help prevent skin breakdown of the heels and elbows with client repositioning.
The nurse should identify that balanced suspension skeletal traction is managed through the use of pins, pulleys, weights, and frames and that the client does not wear a boot.
The nurse should ensure the weights hang freely at all times.
A nurse is reinforcing teaching with a client who has gonorrhea. Which of the following information should the nurse include? - ....ANSWER..."You are at risk for infertility with this infection, regardless of treatment."
Rationale:
The nurse should inform the client that there is a risk for infertility as a result of this infection.
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The nurse should inform the client that sexual partners will require treatment to prevent the risk for reoccurrence of the infection.
The nurse should instruct the client to abstain from sexual contact until treatment is completed and cultures are negative.
The nurse should inform the client that immunity does not occur with this infection and that reoccurrence is possible.
A nurse is caring for a client who has difficulty swallowing. Which of the following actions should the nurse implement to prevent aspirtation? - ....ANSWER...Give the client liquids with increased viscosity.
Rationale:
Thickened liquids are easier for the client to swallow and can prevent aspiration.
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