ATI NCLEX Medical Surgical

ATI NCLEX Medical Surgical Assessment 1 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

• Provide the client with a means of communication
• Maintain the head of the client's bed in a flat position
• Suction the client's endotracheal tube every 4 hr
• Perform oral hygiene for the client every 8 hr - CORRECT ANSWER 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 1 / 4

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

• Sodium 165 mEq/L
• Potassium 5.2 mEq/L
• Urine specific gravity 1.020
• Hct 62% - CORRECT ANSWER 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

• PT 11.5 seconds
• aPTT 35 seconds
• Platelets 80,000
• RBC 4.0 million - CORRECT ANSWER C

platelet range is 150,000-400,000 -- A, PT range is 11-12.5 2 / 4

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

• Change the client's position every 2 hours
• Pad pressure points at the edges of the client's cervical collar
• Palpate the client's abdomen for bladder distention
• Assist the client with quad coughing - CORRECT ANSWER D

The greatest risk to a client who has a cervical spinal cord injury is an obstructed airway; the priority is to ensure the client can clear their airway. Apply abdominal pressure as the client coughs (quad coughing) A nurse is caring for a client who is receiving a blood transfusion. Which of the following findings indicates that the client is experiencing transfusion-associated circulatory overload

• Nasuea
• Hypothermia
• Dyspnea
• Bradycardia - CORRECT ANSWER C

Dyspnea is an indication of possible transfusion associated circulatory overload, leading to hypertension, bounding pulses, and confusion. Dyspnea can also 3 / 4

indicate transfusion related acute lung injury to an anaphylactic response, which also causes wheezing, chest tightness, cyanosis, and low BP -- A, nausea can indicate an acute hemolytic transfusion reaction B, transfusion reactions include acute hemolytic, febrile, mild allergic, and anaphylactic D, bradycardia is not an indication A nurse is assessing a client who has lung cancer and is undergoing radiation therapy to the chest. Which of the following indicates an adverse effect of the therapy

• Hair loss on the scalp
• Sweating at the treatment site
• Altered taste sensations
• Intolerance to cold - CORRECT ANSWER C

Altered taste is a result of the release of metabolites by dead cells -- A, client may have hair loss at the treatment site on the chest B, client might have skin changes, such as dryness and increased sensitivity D, avoid heat exposure

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