Exam (elaborations)
ATI NCLEX Medical Surgical Assessment 1
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ATI NCLEX Medical Surgical Assessment 1
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BATI NCLEX MEDICAL SURGICALASSESSMENT 1 QUESTIONS WITH
COMPLETE SOLUTION
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 - A
Use electronic tablet computer, programmable speech generating device, alphabet board, pencil and
paper, etc
--
B, keep head of bed higher than 30 degrees to prevent aspiration and ventilator associated pneumonia.
Turn the client q 2hr to prevent complications related to immobility
C, assess the need to suction q 2-4 hr, but not perform routine suctioning. Base the need for suctioning
on assessments, not a schedule. Unnecessary suctioning can cause bronco spasms and injury tracheal
mucosa
D, oral hygiene should be performed q 2 hr to decrease the risk of ventilator associated pneumonia
A nurse is caring for a client who is 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% - C
Within the expected range of 1.005-1.030
--
A, sodium range is 136-145
B, potassium range is 3.5-5
D, Hct range is 37%-52%
A nurse is monitoring the laboratory findings for a client who is postoperative following a total hip
arthroplasty 6 hr ago. Which of the following values indicates that the client has an increased risk for
bleeding
A. PT 11.5 seconds
B. aPTT 35 seconds
C. Platelets 80,000
D. RBC 4.0 million - C
platelet range is 150,000-400,000
--
A, PT range is 11-12.5
B, aPTT range is 30-40 seconds
D, RBC range is 4.2-6.1 million. A low RBC can indicate that bleeding has occurred, but it does not
indicate that the client is at risk for bleeding
A nurse is admitting a client who has a cervical spinal cord injury following a motor vehicle crash. Which
of the following interventions is the nurse's priority while caring for this client
A. Change the client's position every 2 hours
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