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ATI RN ADULT MEDICAL SURGICAL EXAM LATEST FOR 2024 SERIES GUARANTEED PASS==
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ATI RN ADULT MEDICAL SURGICAL EXAM LATEST FOR 2024 SERIES GUARANTEED PASS==
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ATI RN ADULT MEDICAL SURGICAL EXAM LATEST FOR 2024 SERIES GUARANTEED PASS==A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the
following instructions should the nurse include? - ANSWER-Flex the foot every hour when awake.
Rationale: The nurse should instruct the client to flex the foot every hour to reduce the risk for
thromboembolism and promote venous return.
A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the
following findings is an indication of lung re-expansion? - ANSWER-Bubbling in the water seal chamber
has ceased.
Rationale: Bubbling in the water seal chamber ceases when the lung re-expands.
A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation.
Which of the following values should the nurse identify as a desired outcome for this therapy? -
ANSWER-INR 2.5
Rationale: Clients receive warfarin therapy to decrease the risk of stroke, myocardial infarction (MI), or
pulmonary emboli (PE) from blood clots. Since warfarin is an anticoagulant, the medication must be
monitored to ensure the anticoagulation is within the therapeutic range and prevent hemorrhage (high
levels of anticoagulation) or stroke, MI, or PE (low levels of anticoagulation). An INR of 2.5 is within the
targeted therapeutic range of 2 to 3 for a client who has atrial fibrillation.
A home health nurse is providing teaching to a client who has a stage 1 pressure injury on the greater
trochanter of his left hip. Which of the following instructions should the nurse include in the teaching? -
ANSWER-Change position every hour
Rationale: Changing position every 1 to 2 hr decreases pressure on bony prominences. The nurse should
also instruct the client to limit the angle of the hips when in a lateral position to no more than 30°. This
positioning prevents direct pressure on the trochanter.
Compartment syndrome - ANSWER-Early signs: intense pain with movement, capillary refill less than 2
seconds, erythema of the toes, bounding distal pulses
Hemolytic transfusion reaction - ANSWER-Manifestations: chills, back pain, hypertension
Preventing hip dislocation - ANSWER-Action: place two bed pillows between the legs when in bed
,Allergic cross-reactivity - ANSWER-Risk for client with allergy to bananas: latex
Incentive spirometer - ANSWER-Instruction: hold breaths about 3 to 5 seconds before exhaling
Low serum potassium level - ANSWER-Intervention: initiate cardiac monitoring for the client
Peritoneal dialysis - ANSWER-Action: hang the drainage bag below the client's abdomen
Impaired vestibulocochlear nerve - ANSWER-Finding: disequilibrium with movement
Postoperative care after cholecystectomy - ANSWER-Intervention: apply compression stockings to the
lower extremities
Discharge teaching after mastectomy - ANSWER-Statement: expect less than 25 mL of secretions per day
in the drainage devices
Using a metered-dose rescue inhaler - ANSWER-Statement: exhale fully before bringing the inhaler to
your lips
Total parenteral nutrition (TPN) - ANSWER-Finding requiring notification of provider: calcium level 11.5
mg/dL
Setting up a sterile field - ANSWER-Actions: grasp 2.5 cm (1 in) of the outer edge to open the surgical
wrap, place a surgical pack with a sterile drape on the work surface, select a work surface at the nurse's
waist level
Blood alcohol level - ANSWER-Priority action: obtain consent for surgery
Increased intracranial pressure - ANSWER-First sign of deteriorating neurological status: altered level of
consciousness
, Skin cancer screening - ANSWER-Finding indicating melanoma: raised lesion with a rolled border
Diabetes insipidus - ANSWER-Medication: desmopressin
Insertion of a non-tunneled central venous catheter - ANSWER-Action: confirm the correct position of
the line by obtaining a blood sample
Discharge teaching for chronic urinary tract infections - ANSWER-Instruction: drink 2 to 3 L of fluids daily
Discharge teaching for HIV - ANSWER-Priority information: describe your daily medication schedule
Administering packed RBCs - ANSWER-Action: stop the infusion
Thoracentesis - ANSWER-Priority intervention: determine whether the client has an allergy to local
anesthetics
Bladder cancer - ANSWER-Action: instruct the client to avoid eating raw fruit
Postoperative assessment after appendectomy - ANSWER-Finding requiring reporting to provider:
hemoglobin 10 mg/dL
Assessment of a client with an NG tube - ANSWER-Finding requiring reporting to provider: the client's
abdomen becomes distended and firm
Medications to withhold after CT scan with contrast media - ANSWER-Medication: metformin
Ocular irrigation - ANSWER-First action: collect information about the irritant that caused the injury
Foot care for peripheral arterial disease - ANSWER-Statement indicating understanding: rest in my
recliner with my feet elevated for about an hour every afternoon
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