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ATI Medical Surgical Proctored Exam 2019 Quizlet
1. The client has acute kidney injury (AKI). Which assessment finding requires immediate intervention?
- A. Urine output of 50 ml in the last hour.
- B. Serum potassium of 6.2 mEq/L.
- C. Blood pressure of 150/90 mm Hg.
- D. Serum creatinine of 2.5 mg/dL.
Correct answer: B
Rationale: An elevated serum potassium level of 6.2 mEq/L in a client with AKI can lead to life-threatening cardiac arrhythmias, necessitating immediate intervention. Hyperkalemia is a serious complication in AKI as impaired kidney function can result in the accumulation of potassium in the blood, posing a risk of cardiac arrest. Prompt treatment to lower potassium levels is crucial to prevent cardiac complications in this situation.
2. A client in labor states, 'I think my water just broke!' The nurse notes that the umbilical cord is on the perineum. What action should the nurse perform first?
- A. Administer oxygen via face mask.
- B. Notify the operating room team.
- C. Place the client in Trendelenburg.
- D. Administer a fluid bolus of 500 ml.
Correct answer: C
Rationale: In this scenario, the priority action for the nurse is to place the client in Trendelenburg position. This position helps alleviate pressure on the umbilical cord, preventing compression and ensuring continued blood flow to the fetus. Administering oxygen, notifying the operating room team, or administering a fluid bolus are not the initial priority actions in a cord prolapse situation.
3. A client with schizophrenia is prescribed haloperidol (Haldol). The nurse should monitor the client for which potential side effect?
- A. Tardive dyskinesia.
- B. Orthostatic hypotension.
- C. Photosensitivity.
- D. Hyperglycemia.
Correct answer: A
Rationale: The correct answer is A: Tardive dyskinesia. Haloperidol (Haldol) is an antipsychotic medication that can lead to tardive dyskinesia, a side effect characterized by involuntary, repetitive movements of the face and body. Monitoring for this side effect is crucial to provide timely interventions and prevent further complications.
4. A male client is admitted to the neurological unit. He has just sustained a C-5 spinal cord injury. Which assessment finding of this client warrants immediate intervention by the nurse?
- A. Is unable to feel sensation in the arms and hands.
- B. Has flaccid upper and lower extremities.
- C. Blood pressure is 110/70 and the apical pulse is 68.
- D. Respirations are shallow, labored, and 14 breaths/minute.
Correct answer: D
Rationale: Respirations that are shallow, labored, and at 14 breaths/minute indicate potential respiratory compromise, which is a critical situation requiring immediate intervention to maintain adequate oxygenation and prevent respiratory failure.
5. The client with newly diagnosed osteoporosis is being taught by the nurse about dietary modifications. Which instruction should the nurse include?
- A. Increase your intake of high-calcium foods.
- B. Limit your intake of vitamin D-rich foods.
- C. Avoid foods high in phosphorus.
- D. Increase your intake of high-sodium foods.
Correct answer: A
Rationale: Increasing the intake of high-calcium foods is essential for improving bone density and managing osteoporosis. Calcium is a key mineral necessary for bone health, and individuals with osteoporosis often need higher levels of calcium to help strengthen their bones and prevent further bone loss. Therefore, advising the client to increase their intake of high-calcium foods is the most appropriate dietary modification to support their bone health.
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