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ATI Medical Surgical Proctored Exam 2019 Quizlet
1. A client who underwent a total hip replacement is receiving discharge teaching from a nurse. Which instruction should the nurse include?
- A. Avoid crossing your legs at the knees.
- B. Sit only in low chairs for comfort.
- C. Bend at the waist to pick up objects.
- D. Sleep on the affected side to prevent discomfort.
Correct answer: A
Rationale: The correct instruction the nurse should include is to avoid crossing the legs at the knees. This advice helps prevent dislocation of the new hip joint, which is a common concern after a total hip replacement surgery. Crossing the legs can place stress on the hip joint and increase the risk of dislocation. It is important for the client to follow this precaution to promote proper healing and reduce complications postoperatively.
2. The client with chronic kidney disease (CKD) is receiving hemodialysis. Which finding should be reported to the healthcare provider immediately?
- A. Blood pressure of 150/90 mm Hg.
- B. Weight gain of 2 pounds since the last dialysis session.
- C. Blood glucose level of 120 mg/dl.
- D. Potassium level of 6.5 mEq/L.
Correct answer: D
Rationale: A potassium level of 6.5 mEq/L is dangerously high, a condition known as hyperkalemia, which can lead to severe cardiac complications like arrhythmias and cardiac arrest. Immediate medical intervention is necessary to lower potassium levels to prevent life-threatening outcomes in clients undergoing hemodialysis.
3. A client with a severe head injury is admitted to the intensive care unit (ICU). Which finding should the nurse report to the healthcare provider immediately?
- A. Urine output of 100 mL/hour.
- B. Intracranial pressure (ICP) of 20 mm Hg.
- C. Respiratory rate of 12 breaths/minute.
- D. Mean arterial pressure (MAP) of 70 mm Hg.
Correct answer: B
Rationale: An Intracranial Pressure (ICP) of 20 mm Hg is at the upper limit of normal and may indicate increased intracranial pressure, which is a critical finding in a client with a severe head injury. Elevated ICP can lead to further brain damage and must be addressed promptly to prevent complications such as herniation. Monitoring and managing ICP are crucial in the care of patients with head injuries in the ICU.
4. During an admission physical assessment, the nurse is examining a newborn who is small for gestational age (SGA). Which finding should the nurse report immediately to the pediatric healthcare provider?
- A. Heel stick glucose of 65 mg/dL.
- B. Head circumference of 35 cm (14 inches).
- C. Widened, tense, bulging fontanel.
- D. High-pitched shrill cry.
Correct answer: C
Rationale: A widened, tense, bulging fontanel is a critical finding in a newborn as it can indicate increased intracranial pressure. This condition requires immediate attention and intervention to prevent further complications. Monitoring fontanel status is crucial in assessing the newborn's neurological well-being and ensuring early detection of potential issues.
5. A 62-year-old male client with a history of coronary artery disease complains that his heart is 'racing' and he often feels dizzy. His blood pressure is 110/60, and he uses portable oxygen at 2 liters per nasal cannula. Based on the rhythm shown, which prescription should the nurse administer?
- A. Give magnesium via secondary infusion.
- B. Initiate IV heparin solution as per protocol.
- C. Administer IV adenosine (Adenocard).
- D. Prepare for synchronized cardioversion.
Correct answer: C
Rationale: Administering IV adenosine is the appropriate intervention for a client with symptomatic tachycardia to restore normal sinus rhythm. Adenosine is a medication used to treat supraventricular tachycardia (SVT) by interrupting the reentry pathways through the AV node and restoring normal sinus rhythm. It is a rapid-acting medication given as a rapid IV push followed by a saline flush. The dose is typically administered in a healthcare setting where cardiac monitoring is available due to its potential to cause transient asystole.
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