ATI Medical Surgical Proctored Exam

ATI Medical Surgical Proctored Exam Related

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A client with heart failure has gained 2 kg (4.4 lbs) in the past 24 hours. What action should the nurse take first?

  • A. Restrict the client's fluid intake.
  • B. Assess the client's respiratory status.
  • C. Administer diuretics as ordered.
  • D. Notify the healthcare provider.
Correct Answer: B

Rationale: The correct answer is B: Assess the client's respiratory status. The first action should be to assess the client's respiratory status as the weight gain could indicate fluid retention leading to pulmonary congestion, a common complication in heart failure. By assessing the respiratory status, the nurse can determine if there are signs of respiratory distress such as increased work of breathing, crackles, or shortness of breath. This assessment will help in identifying any immediate need for interventions such as oxygen therapy or diuretics. Restricting fluid intake (choice A) is important but not the first step. Administering diuretics (choice C) should be based on assessment findings. Notifying the healthcare provider (choice D) can be done after assessing the client's respiratory status.

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A 72-year-old male client had the Foley catheter removed today, which was inserted during the transurethral resection of the prostate (TURP). The client is concerned about the urinary incontinence he has experienced since removal of the Foley catheter. The nurse should explain to the client that:

  • A. he should not be concerned, because it will be quickly resolved.
  • B. urinary incontinence is usually temporary.
  • C. he should notify the nurse when this happens.
  • D. this is related to the bladder spasms and will soon stop.
Correct Answer: B

Rationale: Urinary incontinence is usually temporary, but the problem may take some time to resolve, especially in an older male. Bladder spasms are not the cause of the client's incontinence.

A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed assistive personnel (UAP). Four hours later, the nurse notes the client's blood pressure is much higher than previous readings & the client's mental status has changed. What action by the nurse would most likely have prevented this negative outcome?

  • A. Determining if the UAP knew how to take blood pressure
  • B. Double-checking the UAP by taking another blood pressure
  • C. Providing more appropriate supervision of the UAP
  • D. Taking the blood pressure instead of delegating the task
Correct Answer: C

Rationale: The correct answer is C: Providing more appropriate supervision of the UAP. By providing adequate supervision, the nurse can ensure that the UAP is performing tasks correctly and can intervene if any issues arise. This would have likely prevented the negative outcome as the nurse could have identified the high blood pressure and changed mental status earlier.

A: Determining if the UAP knew how to take blood pressure - While assessing the UAP's competence is important, it does not address the need for ongoing supervision and oversight.

B: Double-checking the UAP by taking another blood pressure - This approach does not address the root cause of the issue, which is the lack of appropriate supervision.

D: Taking the blood pressure instead of delegating the task - This is not a sustainable solution as delegating tasks to UAPs is a common practice in healthcare settings. Providing appropriate supervision is key to ensuring safe and effective delegation.

What nursing action is most important initially for Ms. Jenkins with pneumococcal pneumonia?

  • A. Administer humidified oxygen, as ordered
  • B. Obtain an order for aspirin
  • C. Auscultate the posterior basal segments for rales and rhonchi
  • D. Explain the diagnosis to the patient
Correct Answer: A

Rationale: Oxygen therapy addresses hypoxemia, a primary concern in pneumonia.

Consider the differences between primary and secondary prevention. Fill in the blanks.

  • A. Secondary
  • B. Primary
  • C. None
  • D. All
Correct Answer: B

Rationale: Secondary prevention focuses on early detection and intervention to halt disease progression, while primary prevention aims to prevent disease onset through healthy behaviors like diet, exercise, and immunizations.

Identify what short-term evaluation technique is appropriate to assess whether the patient has met the following learning goals.

  • A. Demonstration
  • B. Verbalization
  • C. Selection
  • D. Observation
Correct Answer: B

Rationale: Each learning goal requires a different evaluation technique: Demonstration for subcutaneous insulin injection, Verbalization for identifying side effects of Coumadin, Selection for choosing potassium-rich foods, Observation for verbalizing no shortness of breath, and Verbalization for stating readiness to change a dressing. The correct technique depends on the specific goal.

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