ATI Medical Surgical Assessment E
A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following actions should the nurse include in the plan?
• A. Provide the client with a means of communication
• B. Maintain the head of the client's bed in a flat p...
A nurse is planning care for a client who is receiving mechanical ventilation.
Which of the following actions should the nurse include in the plan?
• A. Provide the client with a means of communication
• B. Maintain the head of the client's bed in a flat position
• C. Suction the client's endotracheal tube every 4 hr
• D. Perform oral hygiene for the client every 8 hr
Answer: A
Rationale: Use communication aids like an electronic tablet, alphabet board,
or paper and pencil.
B: The head of the bed should be elevated more than 30 degrees to prevent
aspiration and ventilator-associated pneumonia.
C: Suction should be based on assessment, not a routine. Unnecessary
suctioning can cause bronchospasms and tracheal injury.
D: Oral hygiene should be performed every 2 hours to decrease the risk of
pneumonia.
A nurse is caring for a client receiving IV fluid replacement therapy for
dehydration. Which of the following laboratory results indicates effectiveness
of the treatment?
• A. Sodium 165 mEq/L
, • B. Potassium 5.2 mEq/L
• C. Urine specific gravity 1.020
• D. Hct 62%
Answer: C
Rationale: A urine specific gravity within the normal range of 1.005-1.030
indicates hydration.
A: Sodium range is 136-145.
B: Potassium range is 3.5-5.
D: Hematocrit (Hct) range is 37%-52%.
A nurse is monitoring laboratory findings for a client 6 hours post-op
following total hip arthroplasty. Which value indicates increased bleeding
risk?
• A. PT 11.5 seconds
• B. aPTT 35 seconds
• C. Platelets 80,000
• D. RBC 4.0 million
Answer: C
Rationale: The normal platelet range is 150,000-400,000.
A: PT range is 11-12.5 seconds.
B: aPTT range is 30-40 seconds.
D: A low RBC count indicates bleeding has occurred but does not predict
future bleeding risk.
, A nurse is admitting a client with a cervical spinal cord injury following a
motor vehicle crash. Which intervention is the priority?
• A. Change the client's position every 2 hours
• B. Pad pressure points on the cervical collar
• C. Palpate the abdomen for bladder distention
• D. Assist the client with quad coughing
Answer: D
Rationale: The priority is ensuring the client can clear their airway due to
the risk of respiratory compromise.
A nurse is caring for a client receiving a blood transfusion. Which finding
indicates transfusion-associated circulatory overload?
• A. Nausea
• B. Hypothermia
• C. Dyspnea
• D. Bradycardia
Answer: C
Rationale: Dyspnea suggests circulatory overload, possibly leading to
hypertension, bounding pulses, and confusion. It may also indicate acute
lung injury or anaphylaxis.
A: Nausea can indicate an acute hemolytic reaction.
B: Hypothermia isn't typically related to transfusion overload.
D: Bradycardia is not an indication.
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