MED SURG RN ATI PROCTORED EXAM 2024| 100 ACTUAL EXAM NGN QUESTIONS WITH RATIONALES CORRECT ANSWERS SCORED A+
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Course
Med surg
Institution
Med Surg
A nurse is providing discharge instructions for a client following cataract surgery with insertion of an intraocular lens. Which of the following instruction should the nurse include? - CORRECT ANSWER-Restrict lifting objects greater than 10 pounds
Rationale: the nurse instruct the client to res...
MED SURG RN ATI PROCTORED EXAM 2024|
100 ACTUAL EXAM NGN QUESTIONS WITH
RATIONALES CORRECT ANSWERS SCORED A+
A nurse is providing discharge instructions for a client following cataract surgery with insertion of an
intraocular lens. Which of the following instruction should the nurse include? - CORRECT ANSWER-
Restrict lifting objects greater than 10 pounds
Rationale: the nurse instruct the client to restrict lifting objects greater than 10 pounds to reduce the
rest for increased interocular pressure
A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA).
Which of the following parameters should the nurse use first in order to assess the client's pain level? -
CORRECT ANSWER-A self-report pain rating scale
Rationale: expressive aphasia results from damage to an area of the frontal lobe and is a motor speech
problem. The client who has expressive aphasia is able to understand what is sad, but is unable to
communicate verbally. However, this does not necessarily mean that a client is unable to reliably report
pain. evidence based practice indicates the nurse should first attempt to obtain the client self report of
pain. When assessing a client for pain, the nurse should utilize the hierarchy of pain measures which
begins with self report. It is always better to use a subjective method, such as a client report, instead of
an objective method, such as something that is observable by the nurse, which is much less reliable.
A nurse is assessing a client who has a concussion from a sports injury. Which of the following
manifestations should the nurse expect? - CORRECT ANSWER-Sensitivity to light
Rationale: the nurse should expect a client who has a mild traumatic brain injury, such as a concussion,
to have sensitivity to light and noise
A nurse is caring for a client who has aphasia following a stroke. A family member asks the nurse how
she should communicate with the client. Which of the following responses by the nurse is appropriate? -
CORRECT ANSWER-Incorporate nonverbal cues in the conversation
,Rationale: nonverbal cues, enhance the client's ability to comprehend and use language
A nurse is caring for a client who has Parkinson's disease and is taking diphenhydramine 25 mg PO TID.
Which of the following therapeutic outcome should the nurse expect to see? - CORRECT ANSWER-
Decreased tremors
Rationale: Clients who have Parkinson's disease often experience trembling, muscle rigidity, difficulty
walking and problems with balance and coordination. Antihistamines, like diphenhydramine, have a mild
anticholinergic effect and may be helpful in controlling tremors in the early stage of the disease.
A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following
nursing interventions is of highest priority? - CORRECT ANSWER-Suction saliva from the clients mouth
Rationale: the unconscious client is unable to independently maintain a clear airway and is at risk for
ineffective airway clearance according to the safety and risk reduction priority setting framework,
maintaining the clients airway, breathing, and circulation is the highest priority
Patient admitted with a possible diagnosis of infective endocarditis and prescribed gentamicin. Client is
exhibiting signs of headache, dizziness, nausea and tinnitus. Client's diagnostic lab wailers also indicated
an increase in BUN, creatinine, gentamicin peak level, AST/ALT. - CORRECT ANSWER-The nurse should
identify that the priority hypothesis is that the greatest risk for the client is developing hearing loss due
to antibiotics. Ototoxicity may occur in clients who are receiving aminoglycosides, such as gentamicin. An
increase in BUN, creatinine, gentamicin peak level, ALT/AST all place the client at risk for ototoxicity and
hearing loss. Hearing loss is generally in the high frequency range and is associated with peak
aminoglycoside levels that continue to remain elevated.
A nurse is caring for a client following cataract surgery. Which of the following comments from the client
should the nurse report to the clients provider? - CORRECT ANSWER-"I need something for the pain in
my eye. I can't stand it"
Rationale: following cataract surgery, the client should expect only mild pain and should immediately
report any pain, decrease in vision, or increase in discharge from the eye. Severe eye pain after surgery
might indicate increased intraocular pressure or hemorrhage.
, A nurse is assessing a client who has a spinal cord injury. Which of the following action should the nurse
take to monitor C4 function? - CORRECT ANSWER-Apply downward pressure while the client shrugs their
shoulders upward
Rationale: this assessment monitors the motor function of C4 to C5
A nurse is planning care for a client who had a traumatic brain injury and is emerging restlessly from a
coma. which of the following intervention should the nurse include in the plan? - CORRECT ANSWER-
Reduce stimuli
Rationale: the nurse should reduce stimuli by decreasing the number of visitors, speaking calmly, and
creating a quiet environment
A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebra. When
planning care, the nurse anticipate which of the following types of disability? - CORRECT ANSWER-
Paraplegia
Rationale: Paraplegia or paralysis of both legs, is seen after a SCI below T1
A nurse is caring for a client four hours following evacuation of a subdural hematoma. Which of the
following assessment is the nurses priority? - CORRECT ANSWER-Respiratory status
Rationale: When using the airway, breathing,
circulation approach to client care, the nurse should place the priority on assessing the client's
respirations, noting the rate and pattern and evaluating arterial blood gases. Following intercranial
surgery, even slight hypoxia can worsen cerebral ischemia.
A nurse is caring for an older adult client who has dementia and handles anxiety by confabulating. The
nurse should recognize confabulation when the client .. - CORRECT ANSWER-Makes up stories when he is
unable to remember actual events
Rationale: Confabulating is filling in gaps in memory by fabrication. A client who has dementia may do
this unconsciously to cover for and decrease anxiety about memory gaps.
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