NGN Exam Retake 2 ATI RN Medical Surgical Med Surg A with rationales

NGN Exam Retake 2 ATI RN Medical
Surgical Med Surg A with rationales
A nurse is caring for a client who has a closed head injury and
has an intraventricular catheter placed. Which of the following
findings indicates that the client is experiencing increased
intracranial pressure (ICP)? (Select all that apply.)
A. Flat jugular veins
B. A Glasgow Coma Scale score of 15
C. Sleepiness exhibited by the client
D. Widening pulse pressure
E. Decerebrate posturing - CORRECT ANSWER C, D, E
Flat jugular veins is incorrect. With increased ICP, the jugular
veins are typically distended.
A Glasgow Coma Scale score of 15 is incorrect. A Glasgow Coma
Scale score of 15 indicates neurological functioning within the
expected reference range for eye opening, motor, and verbal
response.
Sleepiness exhibited by the client is correct. Sleepiness or
difficulty arousing the client from sleep is an indication of
increased ICP.
Widening pulse pressure is correct. A widening pulse pressure
(increase in systolic with concurrent decrease in diastolic blood
pressure) is an indication of increased ICP.
Decerebrate posturing is correct. Both decerebrate and
decorticate posturing indicate increased ICP.
A nurse is preparing a client who has supraventricular tachycardia
for elective cardioversion. Which of the following prescribed
medications should the nurse instruct the client to withhold for 48
hr prior to cardioversion?
A. Enoxaparin
B. Metformin
C. Diazepam
D. Digoxin - CORRECT ANSWER D. Digoxin
Cardiac glycosides, such as digoxin, are withheld prior to
cardioversion. These medications can increase ventricular
irritability and put the client at risk for ventricular fibrillation after
the synchronized countershock of cardioversion.
AA
A nurse is assessing a client who has acute cholecystitis. Which
of the following findings is the nurse's priority?
A. Anorexia
B. Abdominal pain radiating to the right shoulder
C. Tachycardia
D. Rebound abdominal tenderness - CORRECT ANSWER C.
Tachycardia
The nurse should wear a lead apron when providing direct care to
provide protection from the radiation source and not turn their
back toward the client, because the apron only shields the front of
the body. The nurse should also wear a dosimeter film badge to
measure radiation exposure.
A nurse is preparing to administer a unit of packed RBCs to a
client. Which of the following actions should the nurse take?
A. Remain with the client for the first 15 min of the infusion
B. Prime the blood administration IV tubing with lactated Ringer's
solution
C. Verify the client's identity by using the client's room number
prior to starting the transfusion
D. Infuse the unit of packed RBCs within 8 hr - CORRECT
ANSWER A. Remain with the client for the first 15 min of the
infusion
The nurse should remain with the client for the first 15 to 30 min
of the infusion because hemolytic reactions usually occur during
the infusion of the first 50 mL of blood.
A nurse is caring for a client who presents to a clinic for a 1-week
follow-up visit after hospitalization for heart failure. Based on the
information in the client's chart, which of the following findings
should the nurse report to the provider?
A. Potassium 4.1 mEq/L
B. Heart rate 55/min
C. SaO2 92%
D. Weight 67.1 kg (148 lb) - CORRECT ANSWER B. Heart rate
55/mi