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1. A nurse is caring for a client wh...
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ATI RN ADULT MEDICAL SURGICAL PROCTORED EXAM 2023/2024 VERSION (NGN) WITH 100% CORRECT ANSWERS 1. A nurse is providing care for a woman in the first stage of labor. Upon assessment, the nurse notices the umbilical cord ha s descended through the vaginal opening ahead of the baby's presenting part. Which of the following is the most appropriate action for the nurse to take first? - Contact the physician/midwife immediately - Insert a gloved hand into the vagina to relieve pressure on the cord. - Reassure the client that this is a normal part of labor - Document the findings and continue to monitor the fetal heart rate 2. How should a nurse respond if a colleague wraps an arm around them and comments, "I'm sure you're an excellent lover" - Report the incident to a supervisor or human resources department to addres s the inappropriate behavior according to the workplace policies. - Respond by clearly stating that such personal comments are not acceptable in a professional setting and request that it not happen again. - Politely ask the colleague to remove their arm and express that the comment is inappropriate and makes them uncomfortable. - Ignore the comment and physical gesture at the moment, but document the incident and seek advice from a trusted mentor on how to proceed. 3. When a nurse observes neck flushing and a rapid heartbeat in a patient receiving intravenous vancomycin, what steps should the nurse take? - Decrease the infusion rate to prevent further adverse effects. - Notify the healthcare provider or physician of the patient's symptoms, as they may indicate an adverse reaction to the medica tion. - Monitor the patient's vital signs closely, including blood pressure and oxygen saturation, to assess their condition. - Provide supportive care to the patient, such as ensuring they are comfortable and administering prescribed treatments for the reacti on, if any. 4. When conducting an assessment on an elderly male client at home, what should a nurse prioritize? - Mobility and balance issues. - Dysphagia - Medication adherence and understanding. - Signs of cognitive decline or confusion. 5. What should be included in the care plan for a patient with Alzheimer's disease by a nurse in a long -term care facility? -Talk the client through tasks one step at a time. -Assign complex new tasks daily to challenge cognitive skills. -Frequently rearrange the room to provide variety. -Limit social interactions to reduce overstimulation. 6. In managing a cancer patient who has been prescribed ondansetron for chemotherapy - induced nausea, what side effect should a nurse monitor for? - Increased appetite - Headache - Improved hair growth - Enhanced sense of taste 7. What adverse effect of metronidazole should a nurse warn a patient about regarding
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