NGN ATI RN Adult Medical Surgical Exam 2023 A Version 1| Questions and Verified Answers| 100% Correct| A Grade
QUESTION
A nurse is providing
... [Show More] follow-up care for a client who sustained a compound fracture 3 weeks ago. The nurse should recognize that an unexpected finding for which of the following laboratory values is a manifestation of osteomyelitis and should be reported to the provider?
Answer:
Sedimentation rate
Rational:
An increased sedimentation rate occurs when a client has any type of inflammatory process, such as osteomyelitis.
QUESTION
A nurse in an emergency department is caring for a client who has
full-thickness burns over 20% of their total body surface area. After ensuring a patent airway and administering oxygen, which of the following items should the nurse prepare to administer first?
Answer:
IV Fluids
Rational:
After establishing that the client's airway is secure and administering oxygen, evi- dence-based practice indicates that the nurse should prepare to administer IV fluids to provide circulatory support.
QUESTION
A nurse is assessing a client who has advanced lung cancer and is re- ceiving palliative care. The client has just undergone thoracentesis. The nurse should expect a reduction in which of the following common manifestations of advanced cancer?
Answer:
Dyspnea
Rational:
Thoracentesis, the removal of pleural fluid, can temporarily relieve hypoxia and thus ease the client's breathing and improve comfort.
QUESTION
A nurse is administering packed RBCs to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction?
Answer:
Low back pain and apprehension
Rational:
Hemolytic transfusion reactions result from the infusion of incompatible blood prod- ucts and create a systemic inflammatory response. Manifestations include low back pain, hypotension, tachycardia, and apprehension.
QUESTION
A nurse is caring for a client who has increased intracranial pressure (ICP) and is receiving mannitol via continuous IV infusion. Which of the following findings should the nurse report to the provider as an adverse effect of this
medication?
Answer:
Crackles heard on auscultation
Rational:
Mannitol is an osmotic diuretic that prevents the reabsorption of water in the kidneys, thus increasing urinary output. With the exception of the brain, mannitol can leave the vascular system at the capillary site, which can result in edema. The nurse should identify crackles as a manifestations of pulmonary edema and notify the provider. Other manifestations include dyspnea and decreased oxygen saturation.
QUESTION
A nurse is teaching a group of newly licensed nurses about pain manage- ment for older adult clients. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?
Answer:
"Ibuprofen can cause gastrointestinal bleeding in older adult clients. "
Rational:
A common adverse effect of ibuprofen is gastrointestinal bleeding, and older adult clients have an increased risk for gastrointestinal toxicity and bleeding.
QUESTION
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?
Answer:
Initiate airborne precautions.
Rational:
This client is 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.
QUESTION
A nurse is caring for a client who is having a seizure. Which of the following interventions is the nurse's priority?
Answer:
Turn the client to the side.
Rational:
The greatest risk to this client is hypoxia from an impaired airway. Therefore, the priority intervention the nurse shoul [Show Less]