ATI PN Adult Medical Surgical 2023 Proctored Exam NGN Content Mastery Series Questions and Answers with Rationales

1. A nurse is reviewing the medical record of a client who has a prescription for morphine. Which of the following findings should the nurse report to the provider? A) Respiratory rate of 14/min B) Blood pressure of 118/76 mmHg C) Urinary retention D) Mild constipation Answer: C) Urinary retention Rationale: Urinary retention is a serious adverse effect of morphine that requires provider notification. Morphine can cause urinary retention by increasing smooth muscle tone in the bladder sphincter, which can lead to urinary obstruction if not addressed. 2. A nurse is caring for a client who is at risk for developing pressure ulcers. Which of the following actions should the nurse take? A) Apply a heating pad to bony prominences B) Massage reddened bony prominence areas vigorously C) Position pillows between the bony prominences D) Keep the head of bed elevated at 45 degrees at all times Answer: C) Position pillows between the bony prominences Rationale: Placing pillows between bony prominences (such as the knees and ankles) reduces direct pressure and friction on vulnerable skin areas, thereby decreasing the risk of pressure ulcer development. 3. A nurse is caring for a client who is postoperative and is receiving an IV infusion of cefazolin. Ten minutes after beginning the infusion, the client reports intense itching. Which of the following actions should the nurse take first? A) Administer diphenhydramine IV B) Notify the provider immediately C) Slow the infusion rate D) Stop the medication infusion Answer: D) Stop the medication infusion Rationale: Intense itching shortly after starting an antibiotic infusion suggests a hypersensitivity or allergic reaction. The first priority is to stop the infusion to prevent further exposure to the allergen and to prevent the reaction from escalating to anaphylaxis.