ATI Medical Surgical Proctored Exam

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When planning care, what factors should the nurse consider when utilizing evidence-based practice (EBP)? (Select ONE that does not apply)

  • A. Cost-saving measures
  • B. Nurse's expertise
  • C. Client preferences
  • D. Research findings
Correct Answer: A

Rationale: The correct answer is A: Cost-saving measures. When utilizing evidence-based practice, the nurse should prioritize providing care based on research findings, considering client preferences, and leveraging their expertise. Cost-saving measures should not be the primary factor influencing care decisions as the focus should be on delivering the most effective and appropriate care based on evidence. Ignoring research findings, client preferences, or the nurse's expertise could compromise the quality of care provided. Thus, cost-saving measures are not a factor to consider when planning care with evidence-based practice.

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Match the phases of the nursing process with the descriptions (phases may be used more than once).

  • A. None
  • B. Analysis of data
  • C. Priority setting
  • D. Nursing interventions
Correct Answer: B

Rationale: Analysis of data corresponds to the Diagnosis phase, where health problems are identified based on assessed data.

Felicia's family is concerned because Felicia states that she is hearing voices. This is a sign of

  • A. Bipolar disorder.
  • B. Schizophrenia.
  • C. Panic disorder.
  • D. Bulimia nervosa.
Correct Answer: B

Rationale: Auditory hallucinations are a hallmark symptom of schizophrenia.

A client is 4 hours postoperative following abdominal surgery. The client's blood pressure has dropped from 120/80 mm Hg to 90/60 mm Hg. What action should the nurse take first?

  • A. Administer an IV fluid bolus.
  • B. Check the surgical site for bleeding.
  • C. Place the client in a Trendelenburg position.
  • D. Notify the healthcare provider.
Correct Answer: B

Rationale: The correct answer is B: Check the surgical site for bleeding. This is the first action the nurse should take as a sudden drop in blood pressure postoperatively could indicate internal bleeding, a common complication after abdominal surgery. By assessing the surgical site for bleeding, the nurse can identify and address the source of the hypotension promptly. Administering IV fluids (choice A) may be necessary but should come after determining the cause. Placing the client in Trendelenburg position (choice C) is not recommended as it can worsen venous return and increase intracranial pressure. Notifying the healthcare provider (choice D) should be done after the nurse has assessed the situation and taken immediate action.

A nurse is assessing a client with a history of seizures. Which assessment finding requires immediate intervention?

  • A. The client is experiencing an aura.
  • B. The client's antiseizure medication level is within the therapeutic range.
  • C. The client has been seizure-free for 2 years.
  • D. The client's seizure activity lasts longer than 5 minutes.
Correct Answer: D

Rationale: The correct answer is D because prolonged seizures lasting longer than 5 minutes can lead to status epilepticus, a medical emergency that can cause brain damage or even death. Immediate intervention is necessary to stop the seizure activity. Auras (A) are warning signs of an impending seizure and do not require immediate intervention. Antiseizure medication within therapeutic range (B) indicates proper management. Being seizure-free for 2 years (C) is a positive outcome but does not require immediate intervention unless a seizure occurs.

What priority nursing action should you take?

  • A. Notify the physician immediately
  • B. Administer supplemental oxygen
  • C. Have the student breathe into a paper bag
  • D. Obtain an order for an anxiolytic medication
Correct Answer: C

Rationale: Breathing into a paper bag can help rebalance carbon dioxide levels in a patient experiencing hyperventilation.

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