Adult Medical Surgical ATI

Adult Medical Surgical ATI Related

Review Adult Medical Surgical ATI related questions and content

A client is 12 hours postoperative following colon resection. Which of the following interventions should the nurse include in the plan to reduce respiratory complications?

  • A. Use incentive spirometer every 4 hours while awake.
  • B. Initiate ambulation after discontinuing the NG tube.
  • C. Maintain a supine position with an abdominal binder.
  • D. Splint the incision to support coughing every 2 hours.
Correct Answer: D

Rationale: The correct answer is D because splinting the incision supports coughing, which helps clear secretions and prevents respiratory complications. It is essential postoperatively to prevent atelectasis and pneumonia. Using an incentive spirometer (A) aids in lung expansion but does not directly support coughing. Ambulation (B) promotes circulation but does not address respiratory concerns. Maintaining a supine position with an abdominal binder (C) may restrict diaphragmatic movement and increase the risk of respiratory complications.

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The following data are organized according to Gordon’s functional health patterns.

  • A. 78-year-old woman
  • B. Married, three grown children who all live out of town
  • C. Cares for invalid husband in home with help of daily homemaker
  • D. Vision corrected with glasses; hearing normal
Correct Answer: A

Rationale: N/A

Which measures or drugs may be effective in controlling pain in the physiologic pain process stage of transduction (select all that apply)?

  • A. Distraction
  • B. Corticosteroids
  • C. Epidural opioids
  • D. Local anesthetics
Correct Answer: D

Rationale: The correct answers are D, Local anesthetics, distraction, and NSAIDs target the transduction stage.

Until Mr. Jones’ diagnosis is confirmed, what should be a priority?

  • A. Encouraging rest
  • B. Monitoring intake and output
  • C. Preventing spread of infection to others
  • D. Providing attractive meals
Correct Answer: C

Rationale: The correct answer is C: Preventing spread of infection to others. This is the priority because until Mr. Jones' diagnosis is confirmed, it is crucial to prevent potential transmission of any infectious diseases to others. Encouraging rest (choice A) and providing attractive meals (choice D) are important for overall well-being but not as critical as preventing the spread of infection. Monitoring intake and output (choice B) is important for assessing Mr. Jones' health status but does not directly address the potential risk of infecting others. Therefore, choice C is the most immediate priority to ensure the safety of others.

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.

What is the primary symptom of hordeolum?

  • A. Redness and swelling
  • B. Itching
  • C. Blurred vision
  • D. Dry eyes
Correct Answer: A

Rationale: Hordeolum, or stye, presents with localized redness and swelling of the eyelid.

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