NGN ATI RN Comprehensive 2023 B Version 1 | Questions and Verified Answers| 100% Correct| A Grade
QUESTION
A nurse is caring for a client who is
... [Show More] postoperative following administration of general anesthesia.
Vital Signs
0830:
Temperature 36.9° C (98.5° F) Heart rate 134/min Respiratory rate 28/min Blood pressure 92/52 mm Hg Oxygen saturation 89% on room air
Nurses' Notes
0830:
Client is postoperative following an inguinal hernia repair.Apical pulse 134/min and irregular Client reports dyspnea.
Diagnostic Results
0835:
Arterial blood gases (ABGs) pH 7.30 (7.35 to 7.45) PCO2 64 mm Hg (35 to 45 mm
Answer:
Condition: Malignant hyperthermia
Actions: administer dantrolene and administer oxygen
Parameters to monitor: Hypercapnia and muscle rigidity
Upon recognizing and analyzing the client cues of tachycardia, tachypnea, hypotension, and irregular heart rhythm, the nurse's priority hypothesis should be that this client is most likely experiencing malignant hyperthermia and that it is important to generate solutions and take actions that will correct dysrhythmias, provide oxygen to tissues, correct electrolyte imbalances, and reverse metabolic and respiratory acidosis. Therefore, the nurse should prepare to administer dantrolene and administer oxygen. The nurse should monitor the PCO2 level on the client's ABGs for hypercapnia and observe the client for muscle rigidity of the jaw and chest muscles.
QUESTION
A nurse is providing teaching to the guardians of a newborn about measures to prevent sudden unexpected infant death (SUID). Which of the following guardian statements indicates an understanding of the teaching?
A. "I will not allow anyone to smoke near my baby."
B. "I will place bumper pads in my baby's crib."
C. "My baby's head should be placed on a pillow for sleeping."
D. "My baby should sleep in a side-lying position."
Answer:
A. "I will not allow anyone to smoke near my baby."
This statement by the guardian indicates an understanding of the nurse's instructions. Research indicates a strong correlation between exposure to cigarette smoke and the occurrence of SUID.
Incorrect:
The guardians should not place bumper pads in the infant's crib because they increase the risk for suffocation. Therefore, this is a risk factor for SUID.
The guardians should not place the infant's head on a pillow for sleeping because it increases the risk for suffocation. Therefore, this is a risk factor for SUID.
The guardians should place the child in a supine position for sleeping to prevent SUID.
QUESTION
The nurse is updating the plan of care for a client who is 48 hr postoperative following a laryngectomy and is unable to speak. Which of the following actions should the nurse plan to take first?
A. Determine the client's reading skills.
B. Instruct the client on esophageal speech technique.
C. Provide the client with an alphabet board.
D. Show the client how to use an artificial larynx.
Answer:
A. Determine the client's reading skills.
The first action the nurse should take when using the nursing process is to assess the client. By determining the client's level of reading skills and cognition, the nurse can best provide the client with a variety of customized techniques to practice and use after verbal skills are lost.
Incorrect
The nurse should instruct the client on the technique for esophageal speech and allow time for the client to practice. However, there is another action the nurse should take first.
The nurse should provide the client with an alphabet board and demonstrate how to use it for communicating after verbal skills are lost. However, there is another action the nurse should take first.
The nurse should show the client how to use an artificial larynx, called an electrolarynx, for communicating after verbal skills are lost following surgery. However, there is another action the nurse should take first.
QUESTION
A nurse is caring for a client who is postoperative following an appendectomy.
Nurses' Notes
1800:
Client alert and oriented to person, place, time, and situation.Skin warm and dry.Lungs clear on auscultation Bowel sounds hypoactive in all four quadrants. Urine clear yellow Incisional dressing clean and dry. Client reports pain as 6 on a scale of 0 to 10.1815:
Morphine administered as prescribed.2000:
Client reports abdominal pain as 10 on a scale of 0 to 10. Client reports nausea, no vomiting.
Answer:
Which of the following 4 client findings should the nurse report to the provider?
- Oxygen saturation
- Heart rate
- Pain level
- Nausea
When recognizing cues, the nurse should identify that the findings of pain, nausea, heart rate, and oxygen saturation are unexpected findings for a client who is postoperative following an appendectomy. These findings should be reported to the provider.
QUESTION
A nurse in an emergency department (ED) is assessing a client.
Medical History
1030:
Diagnosed with schizophrenia 2 years ago
Migraine headaches
Unresponsive to second-generation medications (clozapine and risperidone), changed to first-generation medication 6 months ago
Current medications:
Haloperidol 5 mg PO TIDSumatriptan 50 mg PO every 2 hr PRN headache
Vital Signs
1030:
Heart rate 122/minRespiratory rate 28/minBlood pressure 182/85 mm HgTemperature 39.7° C (103.5° F)Oxygen saturati
Answer:
Condition: Neuroleptic malignant syndrome
Action: hold the client's antipsychotic medications and apply a cooling blanket
Monitor: temperature and hydration status
Upon recognizing and analyzing the client cues of decreased responsiveness, muscle rigidity, posturing, diaphoresis, and vital signs that are outside the expected reference ranges, the nurse's priority hypotheses should be that this client is most likely experiencing neuroleptic malignant syndrome, which is related to the client's haloperidol therapy. It is important to generate solutions and take actions that will decrease the client's temperature, blood pressure, heart rate, and respiratory status, which will improve the client's neurological status. The nurse should hold the client's antipsychotic medications and apply a cooling blanket to reduce the client's temperature. Neuroleptic malignant syndrome is a life-threatening condition. Therefore, the nurse should monitor the client's laboratory and arterial blood gas valu
QUESTION
A nurse is caring for a client following a laparoscopic cholecystectomy.
Nurses' Notes
1030: [Show Less]