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Exam Retake 2 ATI RN Medical Surgical Med Surg A with rationales 2024
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Exam Retake 2 ATI RN Medical Surgical Med Surg A with rationales 2024
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Exam Retake 2 ATI RN Medical SurgicalMed Surg A with rationales 2024
A nurse is caring for a client who has a closed head injury and has an intraventricular
catheter placed. Which of the following findings indicates that the client is experiencing
increased intracranial pressure (ICP)? (Select all that apply.)
A. Flat jugular veins
B. A Glasgow Coma Scale score of 15
C. Sleepiness exhibited by the client
D. Widening pulse pressure
E. Decerebrate posturing - ANS-C, D, E
Flat jugular veins is incorrect. With increased ICP, the jugular veins are typically
distended.
A Glasgow Coma Scale score of 15 is incorrect. A Glasgow Coma Scale score of 15
indicates neurological functioning within the expected reference range for eye opening,
motor, and verbal response.
Sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the client
from sleep is an indication of increased ICP.
Widening pulse pressure is correct. A widening pulse pressure (increase in systolic with
concurrent decrease in diastolic blood pressure) is an indication of increased ICP.
Decerebrate posturing is correct. Both decerebrate and decorticate posturing indicate
increased ICP.
A nurse is preparing a client who has supraventricular tachycardia for elective
cardioversion. Which of the following prescribed medications should the nurse instruct
the client to withhold for 48 hr prior to cardioversion?
A. Enoxaparin
B. Metformin
C. Diazepam
D. Digoxin - ANS-D. Digoxin
Cardiac glycosides, such as digoxin, are withheld prior to cardioversion. These
medications can increase ventricular irritability and put the client at risk for ventricular
,fibrillation after the synchronized countershock of cardioversion.
AA
A nurse is assessing a client who has acute cholecystitis. Which of the following
findings is the nurse's priority?
A. Anorexia
B. Abdominal pain radiating to the right shoulder
C. Tachycardia
D. Rebound abdominal tenderness - ANS-C. Tachycardia
When using the urgent vs. nonurgent approach to client care, the nurse should
determine that the priority finding is tachycardia. Tachycardia is a manifestation of biliary
colic, which can lead to shock. The nurse should position the head of the client's bed flat
and report this finding immediately to the provider.
A nurse is preparing to admit a client who has dysphagia. The nurse should plan to
place which of the following items at the client's bedside?
A. Suction machine
B. Wire cutters
C. Padded clamp
D. Communication board - ANS-A. Suction machine
The nurse should ensure that a suction machine is at the bedside of a client who has
dysphagia to clear the client's airway as needed and reduce the risk for aspiration.
A nurse is caring for a client who is having a seizure. Which of the following
interventions is the nurse's priority?
A. Loosen the clothing around the client's neck
B. Check the client's pupillary response
C. Turn the client to the side
D. Move furniture away from the client - ANS-C. Turn the client to the side
The greatest risk to this client is hypoxia from an impaired airway. Therefore, the priority
intervention the nurse should take is to place the client in a side-lying position to prevent
aspiration.
A nurse is providing teaching to a client who has hypothyroidism and is receiving
levothyroxine. The nurse should instruct the client that which of the following
supplements can interfere with the effectiveness of the medication? A. Ginkgo
biloba
, B. Glucosamine
C. Calcium
D. Vitamin C - ANS-C. Calcium
Calcium limits the development of osteoporosis in clients who are postmenopausal and
works as an antacid. Calcium supplements can interfere with the metabolism of a
number of medications, including levothyroxine. The nurse should instruct the client to
avoid taking calcium within 4 hr of levothyroxine administration.
A nurse is planning to irrigate and dress a clean, granulating would for a client who has
a pressure injury. Which of the following actions should the nurse take? A. Apply a
wet-to-dry gauze dressing
B. Irrigate with hydrogen peroxide solution
C. Use a 30-mL syringe
D. Attach a 24-gauge angiocatheter to the syringe - ANS-C. Use a 30-mL syringe
The nurse should use a 30-mL to 60-mL syringe with an 18- or 19-gauge catheter to
deliver the ideal pressure of 8 pounds per square inch (psi) when irrigating a wound. To
maintain healthy granulation tissue, the wound irrigation should be delivered at between
4 and 15 psi.
A nurse is providing teaching to a female client who has a history of urinary tract
infections (UTIs). Which of the following information should the nurse include in the
teaching?
A. Avoid foods that are high in ascorbic acid
B. Add oatmeal to the water when taking a tub bath
C. Urinate every 6 hr
D. Take daily cranberry supplements - ANS-D. Take daily cranberry supplements
The client should take cranberry supplements or drink low-fructose cranberry juice
because it contains compounds that adhere to the urinary tract wall, decreasing the risk
for developing a UTI.
A nurse is providing teaching to a client who has esophageal cancer and is to undergo
radiation therapy. Which of the following statements should the nurse identify as an
indication that the client understands the teaching?
A. "I will was the ink markings off the radiation area after each treatment." B. "I will use
my hands rather than a washcloth to clean the radiation area." C. "I will be able to be
out of the sun 1 month after my radiation treatments are over." D. "I will use a heating
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