a nurse is assessing a client with a history of seizures which assessment finding requires immediate intervention
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Nursing Elites

ATI RN

ATI Medical Surgical Proctored Exam

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

Correct answer: D

Rationale: Seizure activity lasting longer than 5 minutes requires immediate intervention as it can lead to status epilepticus, a medical emergency.

2. A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates an understanding of the teaching?

Correct answer: "If I could lose about 50 pounds, I might stop having so many apneic episodes."

Rationale:

3. A client developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect?

Correct answer: Decreased serum calcium level

Rationale: In fat embolism syndrome (FES), fat globules enter the bloodstream and can lead to various complications, including a decrease in serum calcium levels. This occurs due to the formation of fat emboli in the vessels, which can interfere with calcium metabolism. Therefore, a decreased serum calcium level is an expected laboratory finding in a client with fat embolism syndrome.

4. A post-anesthesia care unit nurse is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give the highest priority to?

Correct answer: Arterial blood gases

Rationale: Arterial blood gases are crucial to assess postoperatively in a client who has undergone thoracotomy and lobectomy to monitor oxygenation and ventilation status. Changes in arterial blood gases can indicate respiratory complications or inadequate gas exchange, which are critical issues that need prompt intervention to prevent further complications. While urinary output, chest tube drainage, and pain level are important assessments, monitoring arterial blood gases takes precedence in this specific postoperative scenario to ensure optimal respiratory function and overall patient well-being.

5. A student asks the faculty to explain best practices when communicating with a person from the LGBTQ community. What answer by the faculty is most accurate?

Correct answer: B

Rationale: It is essential not to make assumptions about the health needs of individuals from the LGBTQ community. Each person is unique, and assuming their needs based on their sexual orientation or gender identity can lead to incorrect care and communication. By being open-minded and avoiding assumptions, healthcare providers can create a safe and supportive environment for LGBTQ individuals to discuss their health needs openly and honestly.

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A client is 1 day postoperative following a lobectomy with a chest tube drainage system in place. Which finding by the nurse indicates a need for intervention?
While suctioning the endotracheal tube of a client on a ventilator, the nurse notices an increase in the client's heart rate from 86/min to 110/min, with irregularity. What should the nurse do next?
A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed?
During an assessment in the emergency department, an older adult client with community-acquired pneumonia is found to be confused. Which of the following findings should the nurse expect?

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