2024 EVOLVE MED SURG ATI REAL FINAL EXAM WITH 100+ QUESTIONS AND VERIFIED CORRECT ANSWERS [ALREADY GRADED A+] ||LATTEST VERSION 2024!!

2024 EVOLVE MED SURG ATI REAL
FINAL EXAM WITH 100+ QUESTIONS
AND VERIFIED CORRECT ANSWERS
[ALREADY GRADED A+] ||LATTEST
VERSION 2024!!
A hospitalized client is receiving nasogastric tube feedings via a small-bore tube
and a continuous pump infusion. The client begins to cough and produces a
moderate amount of white sputum. Which action should the nurse take first?
A. Auscultate the client's breath sounds.
B. Turn off the continuous feeding pump.
C. Check placement of the nasogastric tube.
D. Measure the amount of residual feeding. - ANSWER- B
Rationale:
A productive cough may indicate that the feeding has been aspirated. The nurse
should first stop the feeding to prevent further aspiration. Options A, C, and D
should all be performed before restarting the tube feeding if no evidence of
aspiration is present and the tube is in place.
A client is ready for discharge following the creation of an ileostomy. Which
instruction should the nurse include in discharge teaching?
A.
Replace the stoma appliance every day.
B.
Use warm tap water to irrigate the ileostomy.
C.
Change the bag when the seal is broken.
D.
Measure and record the ileostomy output. - ANSWER- C
Rationale: A seal must be maintained to prevent leakage of irritating liquid stool
onto the skin. Option A is excessive and can cause skin irritation and breakdown.
Ileostomies produce liquid fecal drainage, so option B is not necessary. Option D is
not needed.
A nurse is assisting an 82-year-old client with ambulation and is concerned that the
client may fall. Which area contains the older person's center of gravity?
A. Head and neck
B. Upper torso
C. Bilateral arms
D. Feet and legs - ANSWER- B
Rationale: Stooped posture results in the upper torso becoming the center of
gravity for older persons. The center of gravity for adults is the hips. However, as a
person grows older, a stooped posture is common because of changes caused by
osteoporosis and normal bone degeneration. Furthermore, the knees, hips, and
elbows flex. The head and neck and feet and legs are not the center of gravity in
the older adult. Although the arms comprise a part of the upper torso, they do not
reflect the best and most complete answer.
A client with hypertension has been receiving ramipril, 5 mg PO, daily for 2 weeks
and is scheduled to receive a dose at 0900. At 0830, the client's blood pressure is
120/70 mm Hg. Which action should the nurse take?
A. Administer the prescribed dose at the scheduled time.
B. Hold the dose and contact the health care provider.
C. Hold the dose and recheck the blood pressure in 1 hour.
D. Check the health care provider's prescription to clarify the dose. - ANSWER- A
Rationale: The client's blood pressure is within normal limits, indicating that the
ramipril, an antihypertensive, is having the desired effect and should be
administered. Options B and C would be appropriate if the client's blood pressure
was excessively low (<100 mm Hg systolic) or if the client were exhibiting signs
of hypotension such as dizziness. This prescribed dose is within the normal dosage
range, as defined by the manufacturer; therefore, option D is not necessary
A client with a nasogastric tube attached to low suction states that she is nauseated.
The nurse assesses that there has been no drainage through the nasogastric tube in
the last 2 hours. Which action should the nurse take first?
A.
Irrigate the nasogastric tube with sterile normal saline.
B.
Reposition the client on her side.
C.
Advance the nasogastric tube 5 cm.
D.
Administer an intravenous antiemetic as prescribed. - ANSWER- B
Rationale: The immediate priority is to determine if the tube is functioning
correctly, which would then relieve the client's nausea. The least invasive
intervention, repositioning the client, should be attempted first, followed by
options A and C, unless either of these interventions is contraindicated. If these
measures are unsuccessful, the client may require option D