Adult Medical Surgical ATI

Adult Medical Surgical ATI Related

Review Adult Medical Surgical ATI related questions and content

The physician has written orders for the client with Excess Fluid Volume. The client's morning assessment includes bounding peripheral pulses, weight gain of 2 pounds, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time?

  • A. Weigh client every morning
  • B. Maintain accurate intake and output
  • C. Restrict fluid to 1500 mL per day
  • D. Administer furosemide (Lasix) 40 mg IV push
Correct Answer: D

Rationale: The correct answer is D: Administer furosemide (Lasix) 40 mg IV push. This is the priority because the client is showing signs of fluid volume excess, such as weight gain, pitting edema, and crackles, which indicate fluid overload in the lungs. Furosemide is a loop diuretic that helps to remove excess fluid from the body quickly, making it crucial in managing excess fluid volume in this situation. Weighing the client daily (A) is important but not as urgent as addressing the immediate symptoms of fluid overload. Maintaining accurate intake and output (B) is essential for overall fluid balance but does not address the immediate excess fluid volume. Fluid restriction (C) may be needed in the long term, but immediate intervention with furosemide is necessary to prevent worsening of symptoms and potential complications.

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To prevent a common, adverse effect of prolonged use of phenytoin sodium (Dilantin), patients taking the drug are instructed to

  • A. avoid crowds and obtain an annual influenza vaccination.
  • B. drink at least 2 L of fluids daily, including 8 to 10 glasses of water.
  • C. eat a potassium-rich, low-sodium diet.
  • D. practice good dental hygiene and report gum swelling or bleeding.
Correct Answer: D

Rationale: Phenytoin can cause gum hyperplasia, so good dental hygiene is essential.

When should discharge planning begin for a patient in a tertiary-care facility?

  • A. On the day of admission
  • B. After the acute crisis is resolved
  • C. When the physician writes the discharge order
  • D. When the patient demonstrates readiness to discuss posthospitalization needs
Correct Answer: A

Rationale: Rationale:
A: Discharge planning should begin on the day of admission to ensure a smooth transition. This early start allows for comprehensive assessment and coordination of post-discharge needs.
B: Waiting until after the acute crisis is resolved may lead to rushed planning and potential gaps in care.
C: Discharge planning should not solely rely on the physician's discharge order as it may not address all aspects of the patient's needs.
D: Patient readiness is important, but starting planning early ensures sufficient time for assessment and interventions.

Which technique facilitates interactions between the nurse and client?

  • A. Ask questions that can be answered with yes or no.
  • B. Sit within the client’s comfort zone.
  • C. Avoid making eye contact.
  • D. Address clients by their first names.
Correct Answer: B

Rationale: Respecting personal space enhances trust and comfort during interactions.

During pulmonary hygiene for a client with pneumonia, a nurse positions the client on his left side in Trendelenburg position. From which of the following lung segments should the nurse expect secretions to be mobilized with the client in this position?

  • A. Lateral segment of the left lower lobe
  • B. Lateral segment of the right lower lobe
  • C. Posterior segment of the right middle lobe
  • D. Posterior segment of the right lower lobe
Correct Answer: B

Rationale: The correct answer is B: Lateral segment of the right lower lobe. In Trendelenburg position on the left side, gravity helps drain secretions from the right lung's lateral segments more effectively. The right lower lobe's lateral segment is the most dependent part of the lung in this position, facilitating secretion mobilization. Choices A, C, and D are incorrect because they do not align with the gravitational effect in Trendelenburg position on the left side, making secretion mobilization less efficient in those segments.

A client in the late stage of inhalation anthrax requires a plan of care. What is appropriate to include in the plan of care?

  • A. Provide respiratory support.
  • B. Place the client in droplet isolation.
  • C. Administer antihypertensive medications.
  • D. Monitor ascites.
Correct Answer: A

Rationale: Step 1: Inhalation anthrax causes severe respiratory distress.
Step 2: Providing respiratory support helps maintain oxygenation.
Step 3: Oxygen therapy or mechanical ventilation may be needed.
Step 4: This choice directly addresses the critical needs of the client.
Summary:
- B: Droplet isolation is not needed as anthrax is not transmitted person-to-person.
- C: Antihypertensive medications are irrelevant to inhalation anthrax treatment.
- D: Ascites monitoring is not a priority in late-stage inhalation anthrax.

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