ATI Adult Medical-Surgical Nursing Nclex Most Asked Questions.

A nurse in an emergency department is assessing a client who was in a MVC. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6℃ (101.4℉), and SaO2 92% on room air. Which of the following actions should the nurse take first? A. Obtain a chest x-ray. B. Prepare for chest tube insertion. C. Administer oxygen via a high-flow mask. D. Initiate IV access. Rationale: C- According to the airway, breathing, and circulation to client care, the nurse should place the priority on administering oxygen via high-flow mask to provide the client oxygen to restore optimal breathing. A nurse on a cardiac unit is caring for a group of clients. The nurse should recognize which of the following clients as being at risk for the development of a dysrhythmia? (Select all that apply.) A. A client who has metabolic alkalosis B. A client who has a serum potassium level of 4.3 mEq/L C. A client who has an SaO2 of 96% D. A client who had COPD E. A client who underwent stent placement in a coronary artery Rationale: A, D, E- A client who has an acid-base imbalance such as metabolic alkalosis is at risk for a dysrhythmia. A client who has lung disease, such as COPD, is at risk for a dysrhythmia. A client who has cardiac disease and underwent a stent placement is at risk for a dysrhythmia. 2. A nurse working on a cardiac unit is admitting a client who is to undergo a cardioversion and is reviewing the health record. Which of the following data requires that the nurse notify the provider to cancel the procedure? (Review the data below for additional client information) MAR: Ferrous Sulfate 200 mg PO 0800 and 2000 Diazepam 2 mg PO 0800 and 2000 Isosorbide 2.5 mg PO 4 times a day AC and HS VITAL SIGNS: 0800 – T 99.5F Blood pressure 142/86 mm Hg Heart rate 88/min and irregular Respirations 20/min HISTORY & PHYSICAL: Bariatric surgery 10 years ago Dyspnea with exertion for 3 years Atrial fibrillation began 3 years ago Client reports taking the following medications for the past 6 weeks: Iron supplement, multivitamin, antilipemic, and nitroglycerin A. Respiratory history B. Vital signs C. Medication history D. Medications to be administered A student nurse is observing a cardioversion procedure and hears the team leader call out, “Stand clear.” The student should recognize the purpose of this action is to alert personnel that A. The cardioverter is being charged to the appropriate setting. B. They should initiate CPR due to pulseless electrical activity. C. They cannot be in contact with equipment connected to the client. D. A time-out is being called to verify correct protocols. Rationale: C- A safety concern for personnel performing cardioversion is to “stand clear” of the client and equipment connected to the client when a shock is delivered to prevent them from also receiving a shock. A nurse is planning care for a client who has severe acute respiratory distress system (SARS). Which of the following actions should be included in the plan of care for this client? (Select all that apply.) A. Administer antibiotics. B. Provide supplemental oxygen. C. Administer antiviral medications. D. Administer of bronchodilators. E. Maintain ventilatory support. Rationale: B, D, E- Providing supplemental oxygen should be included in the plan of care for SARS. Oxygen is administered given to treat severe hypoxemia. Administration of bronchodilators should be included in the plan of care for SARS. Bronchodilators are used to vasodilate the client’s airway. Maintaining ventilatory support should be included in the plan of care for SARS. Intubation can be required to maintain a patent airway. 5. A nurse is caring for a client who is receiving vecuronium for acute respiratory distress syndrome. Which of the following medications should the nurse anticipate administering with this medication? (Select all that apply.) A. Fentanyl B. Furosemide C. Midazolam D. Famotidine E. Dexamethasone Rationale: A, C- Fentanyl is a pain medication used to treat clients who have ARDS when a neuromuscular blocking agent such as vecuronium is administered. Midazolam is a sedative medication used to treat clients who have ARDS when a neuromuscular blocking agent such as vecuronium is administered.