ATI Medical Surgical Assessment E
m m m m
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
m m m m
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
