2024 ATI Med Surg Re take Exam New Latest Version with All Questions and 100 % Correct Answer s and Rationale 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 f irst? A. IV fluids B. Analgesia C. Antibiotics D. Tetanus toxoid ------- Correct Answer --------- A. IV fluids After establishing that the client's airway is secure and administering oxygen, evidence -
based practice indicates that the nurse should prepare to administer IV fluids to provide circulatory support. A nurse is caring for a client who has a leg cast and is returning demonstration on the proper use of crutches while climbing stairs. Identify the sequence the client should follow when demonstrating crutch use. ------- Correct Answer --------- 1. Places body weight on the crutches 2. Advances the unaffected leg onto the stair 3. Shifts weight from the crutches to the unaffected leg 4. Brings the crutches and the affected leg up to the stair The client should first place their body weight on the crutches. Next, they should advance the unaffected leg onto the stair. Third, they should shift their weight from the crutches to the unaffected leg. Last, they should bring the crutches and the affect ed leg up to the stair. A nurse is performing a dressing change for a client who is recovering form a hemicolectomy. When removing the dressing, the nurse notes that a large part of the bowel is protruding through the abdomen. Which of the following actions should the nurse take first? A. Place the client in a supine position B. Measure vital signs C. Cover the wound with a sterile, saline -moistened dressing D. Call for help ------- Correct Answer --------- D. Call for help Evidence -based practice indicates that the nurse should first stay with the client and call for assistance. The client will require emergency surgery and is at risk for shock; therefore, the nurse should obtain immediate assistance. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). A new bag is not available when the current infusion is nearly completed. Which of the following actions should the nurse take? A. Keep the line open with 0.9% sodium chloride until the new bag arrives B. Administer dextrose 10% in water until the new bag arrives C. Flush the line and cap the port until the new bag arrives D. Decrease the infusion rate until the new bag arrives ------- Correct Answer --------- B. Administer dextrose 10% in water until the new bag arrives TPN solutions have a high concentration of dextrose. Therefore, if a TPN solution is temporarily unavailable, the nurse should administer dextrose 10% or 20% in water to avoid a precipitous drop in the client's blood glucose level. A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of the following precautions should the nurse implement? A. Place a padded tongue blade at the client's bedside B. Keep the side rails lowered on the client's bed C. Maintain the client's bed at hip level or above D. Ensure the client has a patent IV ------- Correct Answer --------- D. Ensure the client has a patent IV The nurse should ensure the client has IV access in the event that the client requires medication to stop seizure activity. 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? A. Add full -fat yogurt to the diet B. Add cabbage to the diet C. Replace butter with coconut oil D. Replace shellfish with red meat ------- Correct Answer --------- B. Add cabbage to the diet 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 high in fiber. A nurse in a provider's office is assessing a client who has migraine headaches and is taking feverfew to prevent headaches. The nurse should identify that which of the following client medications interacts with feverfew? A. Metoprolol B. Bupropion C. Naproxen D. Atorvastatin ------- Correct Answer --------- C. Naproxen Both naproxen and feverfew impair platelet aggregation and place the client at risk for bleeding. A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching? A. "I will monitor my blood pressure while taking this medication" B. "I should take a vitamin D supplement to increase the effectiveness of the medication" C. "I should inform the provider if I experience an increased appetite while taking this medication" D. "I will decrease the amount of protein in my diet while taking this medication" ------- Correct Answer --------- A. "I will monitor my blood pressure while taking this medication" The client should monitor their blood pressure while taking this medication because hypertension is a common adverse effect and can lead to hypertensive encephalopathy. AA A nurse is caring for a client who has a prescription for enalapril. The nurse should identify which of the following findings as an adverse effect of the medication? A. Bradycardia B. Tremors C. Orthostatic hypotension D. Drowsiness ------- Correct Answer --------- C. Orthostatic hypotension The nurse should identify that dilation of arteries and veins causes orthostatic hypotension, which is an adverse effect of enalapril. 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? A. Serum sodium level of 145 mEq/L B. Forearm skin tents when pinched C. Respiratory rate decreased D. Urine specific gravity 1.045 ------- Correct Answer --------- D. Urine specific gravity 1.045 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 is caring for a client who is experiencing a tonic -clonic seizure. Which of the following actions should the nurse take? A. Insert a padded tongue blade B. Apply oxygen C. Restrain the client D. Loosen restrictive clothing ------- Correct Answer --------- D. Loosen restrictive clothing The nurse should loosen tight, restrictive clothing to prevent injury and suffocation. A nurse is evaluating a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following client statements indicates the client is successfully coping with the change? A. "It is just easier to let my partner administer my insulin" B. "I used to never worry about my feet. Now, I inspect my feet every day with a mirror" C. "I'm concerned I won't be able to read my blood sugar level because the screen is so small" D. "I know a lot of people who have diabetes and do not take insulin. I wish I didn't have to" ------- Correct Answer --------- B. "I used to never worry about my feet. Now, I inspect my feet every day with a mirror" This statement indicates that the client is successfully coping with the change because the client is performing preventive foot care to reduce the risk for complications. A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take first? A. Check laboratory values of recent hemoglobin and hematocrit levels B. Establish a peripheral IV line for possible transfusion C. Call the laboratory to obtain a stat platelet count D. Obtain vital signs ------- Correct Answer --------- D. Obtain vital signs The first action the nurse should take using the nursing process is to assess the client's vital signs. A client who has portal hypertension can develop esophageal varices, which are fragile and can rupture, resulting in large amounts of blood loss and sho ck. Obtaining vital signs provides information about the client's condition that can contribute to decision making. A nurse is providing discharge teaching to a client who has heart failure and a new prescription for a potassium -sparing diuretic. Which of the following information should the nurse include in the teaching? A. Try to walk at least three times per week for exercise B. To increase stamina, walk for 5 min after fatigue begins C. Take over -the-counter cough medicine for a persistent cough D. Use a salt substitute to reduce sodium intake ------- Correct Answer --------- A. Try to walk at least three times per week for exercise The development of a regular exercise routine can improve outcomes in clients who have heart failure.
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