Ati medical surgical assessment e

ATI Medical Surgical Assessment E
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Amnursemismplanningmcaremformamclientmwhomismreceivingmmechanicalmventilation.mWhichmofm
themfollowingmactionsmshouldmthemnursemincludeminmthemplan

A.m Providemthem clientm withm ammeansm ofm communication
mB.mMaintainmthemheadmofmthemclient'smbedminmamflatmposit

ionmC.mSuctionmthemclient'smendotrachealmtubemeverym4mhr
D.mPerformmoralmhygienemformthemclientmeverym8mhrm-mA
Usemelectronicmtabletmcomputer,mprogrammablemspeechmgeneratingmdevice,malphabetmboar
d,mpencilmandmpaper,metc

--

B,mkeepmheadmofmbedmhighermthanm30mdegreesmtompreventmaspirationmandmventilatormassocia
tedmpneumonia.mTurnmthemclientmqm2hrmtompreventmcomplicationsmrelatedmtomimmobility

C,massessmthemneedmtomsuctionmqm2-
4mhr,mbutmnotmperformmroutinemsuctioning.mBasemthemneedmformsuctioningmonmassessments,mnot
mamschedule.mUnnecessarymsuctioningmcanmcausembroncomspasmsm andminjurymtrachealmmucosa

D,moralmhygienemshouldmbemperformedmqm2mhrmtomdecreasemthemriskmofmventilatormassocia
tedmpneumonia

AmnursemismcaringmformamclientmwhomismreceivingmIVmfluidmreplacementmtherapymformdehydrati
on.mWhichmofmthemfollowingmlaboratorymresultsmindicatesmeffectivenessmofmthemtreatment

A.mSodiumm165mmEq/Lm
B.mPotassiumm5.2mmEq/
L
C.mUrinemspecificmgravitym1.02
0mD.mHctm62%m-mC
Withinmthemexpectedmrangemofm1.005-1.030

--
A,msodiummrangemism136-145

B,mpotassiummrangemism3.5-5

D,mHctmrangemism37%-52%

Amnursemismmonitoringmthemlaboratorymfindingsmformamclientmwhomismpostoperativemfollowingm
amtotalmhipmarthroplastym6mhrmago.mWhichmofmthemfollowingmvaluesmindicatesmthatmthemclientmh
asmanmincreasedmriskmformbleeding

A.mPTm11.5mseconds
mB.maPTTm35msecon

dsmC.mPlateletsm80,0
00
D.mRBCm4.0mmillionm-mC

,plateletmrangemism150,000-400,000

--
A,mPTmrangemism11-12.5

B,maPTTmrangemism30-40mseconds

D,mRBCmrangemism4.2-
6.1mmillion.mAmlowmRBCmcanmindicatemthatmbleedingmhasmoccurred,mbutmitmdoesmnotmindicatemt
hatmthemclientmismatmriskmformbleeding

Amnursemismadmittingmamclientmwhomhasmamcervicalmspinalmcordminjurymfollowingmammotormvehi
clemcrash.mWhichmofmthemfollowingminterventionsmismthemnurse'smprioritymwhilemcaringmformthism
client

A. Changemthemclient'smpositionmeverym2mhours
B. Padmpressurempointsmatmthemedgesmofmthemclient'smcervicalmcoll
armC.mPalpatemthemclient'smabdomenmformbladdermdistention
D.mAssistmthemclientmwithmquadmcoughingm-mD
Themgreatestmriskmtomamclientmwhomhasmamcervicalmspinalmcordminjurymismanmobstructedmairway;m
themprioritymismtomensuremthemclientmcanmclearmtheirmairway.mApplymabdominalmpressuremasmthem
clientmcoughsm(quadmcoughing)

Amnursemismcaringmformamclientmwhomismreceivingmambloodmtransfusion.mWhichmofmthemfollowi
ngmfindingsmindicatesmthatmthemclientmismexperiencingmtransfusion-
associatedmcirculatorymoverload

A. Nasuea
B. Hypothermia
C.mDyspnea
m

D.mBradycardiam-mC
Dyspneamismanmindicationmofmpossiblemtransfusionmassociatedmcirculatorymoverload,mleadingmtomh
ypertension,mboundingmpulses,mandmconfusion.mDyspneamcanmalsomindicatemtransfusionmrelatedmac
utemlungminjurymtomanmanaphylacticmresponse,mwhichmalsomcausesmwheezing,mchestmtightness,mcy
anosis,mandmlowmBP

--
A,mnauseamcanmindicatemanmacutemhemolyticmtransfusionmreaction

B,mtransfusionmreactionsmincludemacutemhemolytic,mfebrile,mmildmallergic,mandmanaphylactic

D,mbradycardiamismnotmanmindication

Amnursemismassessingmamclientmwhomhasmlungmcancermandmismundergoingmradiationmtherapymtom
themchest.mWhichmofmthemfollowingmindicatesmanmadversemeffectmofmthemtherapy

A. Hairmlossmonmthemscalp
B. Sweatingmatmthemtreatmentmsit
emC.mAlteredmtastemsensations
D.mIntolerancemtomcoldm-mC
Alteredmtastemismamresultmofmthemreleasemofmmetabolitesmbymdeadmcells

--

, A,mclientmmaymhavemhairmlossmatmthemtreatmentmsitemonmthemchest

B,mclientmmightmhavemskinmchanges,msuchmasmdrynessmandmincreasedmsensitivity

D,mavoidmheatmexposure

AmnursemismpreparingmtomadministermamunitmofmpackedmRBCsmtomamclientmwhomhasmanemia.mWh
ichmofmthemfollowingmactionsmshouldmthemnursemplanmtomtakem(selectmallmthatmapply)

A. Obtainmpre-transfusionmtemperature
B. PrimemthemIVmtubingmwithmlactatedmRinger's
C. Instructmanmassistivempersonnelmtommonitormthemclientmduringmthemtransfusi
onmD.mVerifymthemclient'smbloodmtypemwithmamsecondmnurse
E.mUsemam20mgaugemIVmneedlemformvenousmaccessm-mA,mD,mE

--
A,mcompletemassessmentmpriormtomtransfusion

B,mprimemtubingmwithmamsolutionmthatmdoesmnotmcausemhemolysismofmPRBCs.mNomLRmorm
5%mdextrose!

C,mnursemshouldmremainmwithmptmformfirstm15mminutesmofmtransfusion

D,mverifymidentification,mbloodmcompatibility,mandmexpirationmofmproductmwithmsecondmnurse

E,mthemnursemshouldmusemamlargemboremneedlemtomtransfusemthemPRBCsmtomreducemthemriskmofm
cellmhemolysismandmobstructionmofmflow

Amnursemismreviewingmthemlaboratorymfindingsmformamclientmwhomismdehydrated.mWhichmofm
themfollowingmBUNmlevelsmshouldmthemnursemexpect

A.m3.6mmg/d
lmB.m8mmg/dL
C.m18.7mmg/dLm
D.m26mmg/dLm-
mD

Normalmrangemism10-
20,mandmelevatedmlevelsmindicatesmrenalmdisease,mdehydration,mshock,mexcessivemproteinminmt
hemdiet,msepsis,mglucocorticoidmuse,mGImbleeding,mormothermconditionsminmwhichmbloodmismrea
bsorbedmfromminjuredmtissues

--
AmlowmBUNmlevelmcanmindicatemmalnutrition,mmalabsorption,mlivermdisease,mfluidmoverload,m
ormnephroticmsyndrome

AmnursemismreviewingmECGmstripsmformseveralmclients.mWhichmofmthemfollowingmimagesmsho
uldmthemnursemidentifymasmatrialmfibrillation

(cannotminsertmpictures,mreadmdescription)

A. multiplemirregularmandmvariablemwavesmatmthembaselinemandmirregularmRmtomRmintervals