ati medical surgical proctored exam ATI Medical Surgical Proctored Exam - Nursing Elites
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Nursing Elites

ATI RN

ATI Medical Surgical Proctored Exam

1. A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active, and has no known risk factors for PE. What action by the nurse is most appropriate?

Correct answer: C

Rationale: The most appropriate action for the nurse in this scenario is to teach the client about factor V Leiden testing. Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events, including pulmonary embolism (PE). In a case where a client has no known risk factors for PE, testing for this genetic disorder is crucial to determine if it is a contributing factor. Encouraging the client to walk or referring them to smoking cessation classes, while beneficial for overall health, are not directly relevant to the development of a PE in this specific case. While it is true that sometimes no cause for a disease is found, prematurely assuming this without appropriate investigations may lead to missed opportunities for preventive measures or treatments.

2. A patient is assessing a client who has just been admitted to the emergency department. The client is having difficulty breathing and is using accessory muscles. What action by the nurse is best?

Correct answer: D

Rationale: Placing the client in a high Fowler's position is the best action in this situation as it helps to maximize lung expansion, improve breathing, and decrease the work of breathing. This position allows for better chest expansion, improving oxygenation and ventilation for the client in respiratory distress.

3. A client with a spinal cord injury at T6 suddenly reports a pounding headache and blurred vision. What action should the nurse take first?

Correct answer: B

Rationale: The client's symptoms of a pounding headache and blurred vision are indicative of autonomic dysreflexia, a potentially life-threatening condition in clients with spinal cord injuries at T6 or above. The nurse's priority action should be to check the client's blood pressure as autonomic dysreflexia can lead to severe hypertension. Identifying and addressing this elevated blood pressure promptly is crucial to prevent serious complications such as seizures, stroke, or even death. Once the blood pressure is assessed and managed, further interventions can be implemented to address the underlying cause of autonomic dysreflexia.

4. A client with end-stage renal disease (ESRD) is receiving hemodialysis. Which assessment finding indicates a need for immediate action?

Correct answer: C

Rationale: A potassium level of 6.5 mEq/L is critically high and can lead to life-threatening cardiac dysrhythmias, requiring immediate intervention. Hyperkalemia is a common complication in clients with ESRD due to the kidneys' inability to excrete potassium effectively. High potassium levels can result in serious cardiac consequences such as arrhythmias, cardiac arrest, and death. Prompt action is necessary to prevent these severe complications.

5. Prior to a thoracentesis, what intervention should the nurse complete?

Correct answer: D

Rationale: Before a thoracentesis procedure, it is crucial to ensure that the client has given informed consent. This process involves explaining the procedure, its risks, benefits, and alternatives to the client, and obtaining their signature on the consent form. Verifying informed consent is a vital legal and ethical step to protect the client's autonomy and ensure they have made an informed decision about the procedure.

Similar Questions

The provider requests the nurse to start an infusion of an inotropic agent on a client. How should the nurse explain the action of these drugs to the client and spouse?
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A nurse cares for a client with chronic obstructive pulmonary disease who has been prescribed continuous oxygen therapy at home. Which statement indicates the client correctly understands the teaching?
How does the pain of a myocardial infarction (MI) differ from stable angina?
A client has a pleural chest tube. Which action should the nurse take to ensure safe use of this equipment?
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