Adult Medical Surgical ATI

Adult Medical Surgical ATI Related

Review Adult Medical Surgical ATI related questions and content

A 35-year-old female client has returned to her room following surgery on her right femur. She has an IV of D5 1/2 NS infusing at 125 cc/hr, and is receiving morphine sulfate 10-15 mg IM q4h prn for pain. The client last voided 5 1/2 hours ago when she was given her preoperative medication. To monitor and promote the return of urinary function after surgery, the nurse should:

  • A. provide food and fluids at the client's request.
  • B. maintain the IV, increasing the rate hourly until the client voids.
  • C. report to the surgeon if the client is unable to void within 8 hours of surgery.
  • D. hold the morphine sulfate injections for pain until the client voids, explaining to the client that morphine sulfate can cause urinary retention.
Correct Answer: C

Rationale: Provision of food and fluids promotes bowel elimination. Postoperative nutritional needs are physician determined, not client determined. Increasing IV fluids postoperatively will not cause a client to void. Any change in the rate of administration of IV fluids is determined by the physician, not the nurse. If the postoperative client with normal kidney function cannot void 8 hours after surgery, the client is retaining urine. The client may need catheterization or medication. The physician will provide orders for either, as necessary. While morphine sulfate can cause urinary retention, withholding pain medication will not ensure that the client will void. The client with uncontrolled pain will probably not be able to void.

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When assessing a client who has just undergone a cardioversion, the nurse finds the respirations are 12. Which action should the nurse take first?

  • A. Try to vigorously stimulate normal breathing.
  • B. Ask the RN to assess the vital signs.
  • C. Measure the pulse oximetry.
  • D. Continue to monitor respirations.
Correct Answer: C

Rationale: Pulse oximetry provides critical data on oxygenation.

Which of the following would have the highest priority in septic shock?

  • A. Monitoring temperature.
  • B. Monitoring pupillary reaction.
  • C. Monitoring airway, breathing, circulation (ABC).
  • D. Monitoring ANA and RF levels.
Correct Answer: C

Rationale: Maintaining ABCs is critical in septic shock.

What are these sensory phenomena called when a client hears voices or sees images that do not objectively exist?

  • A. Mania
  • B. Delusions
  • C. Seasonal affective disorder
  • D. Hallucinations
Correct Answer: D

Rationale: Hallucinations involve perceiving things that are not present, such as hearing voices or seeing images.

What is an example of a pertinent negative finding during a physical examination?

  • A. Chest pain that does not radiate to the arm
  • B. Elevated blood pressure in a patient with hypertension
  • C. Pupils that are equal and react to light and accommodation
  • D. Clear and full lung sounds in a patient with chronic bronchitis
Correct Answer: A

Rationale: The correct answer is 'Chest pain that does not radiate to the arm.' Pertinent negatives highlight clinically significant absences of expected findings, helping rule out certain conditions like cardiac ischemia.

To prevent airway obstruction in the postoperative patient who is unconscious or semiconscious, what will the nurse do?

  • A. Encourage deep breathing
  • B. Elevate the head of the bed
  • C. Administer oxygen per mask
  • D. Position the patient in a side-lying position
Correct Answer: D

Rationale: Side-lying position prevents tongue obstruction and facilitates drainage of secretions.

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