ATI RN
RN ATI Adult Medsurg Proctored Exam 2023 With NGN Questions
Extract:
Question 1 of 5
A nurse is assessing a client who has a new diagnosis of pericarditis. Which of the following findings should the nurse identify as a manifestation of cardiac tamponade?
Correct Answer: B
Rationale: The correct answer is B: Jugular vein distention. In cardiac tamponade, fluid accumulates in the pericardial sac, compressing the heart. This leads to increased pressure in the heart chambers, causing jugular vein distention due to impaired venous return. A: Atrial fibrillation is a common arrhythmia but not specific to cardiac tamponade. C: Bradycardia is not a typical finding in cardiac tamponade as the body tries to compensate for decreased cardiac output. D: Hypotension can be present but is a late sign and not specific to cardiac tamponade.
Question 2 of 5
A nurse is assessing a client who is undergoing radiation therapy for breast cancer. Which of the following findings is an indication to the nurse that the client is experiencing an adverse effect of the therapy?
Correct Answer: A
Rationale: The correct answer is A: Skin changes. This is because skin changes, such as redness, irritation, or peeling, are common adverse effects of radiation therapy. The skin over the treated area may become sensitive and may develop a sunburn-like appearance. This indicates that the radiation is affecting the skin cells. Hypertension (
B), diarrhea (
C), and increased white blood cell count (
D) are not typically associated with adverse effects of radiation therapy for breast cancer. Hypertension may be related to stress or other factors, diarrhea could be due to other causes, and an increased white blood cell count is not a typical adverse effect of radiation therapy.
Question 3 of 5
A nurse is preparing to administer enoxaparin 0.75 mg/kg subcutaneously to a client who weighs 154 lb. The amount available is enoxaparin 60 mg/0.6 mL. How many mL should the nurse administer?
Correct Answer: B
Rationale:
To calculate the dose of enoxaparin, first convert the client's weight from pounds to kilograms: 154 lb/2.2 = 70 kg.
Then, calculate the dose: 0.75 mg/kg x 70 kg = 52.5 mg. Since the concentration is 60 mg/0.6 mL, divide the dose needed by the concentration: 52.5 mg/60 mg x 0.6 mL = 0.5 mL.
Therefore, the correct answer is B (0.5 mL).
Choice A is incorrect as it is less than the calculated dose.
Choice C is incorrect as it is based on the concentration but does not match the calculated dose.
Choice D is incorrect as it is higher than the calculated dose.
Question 4 of 5
A nurse is caring for a group of clients. In which of the following scenarios is the nurse acting as a client advocate?
Correct Answer: B
Rationale: The correct answer is B because referring a client with COPD for palliative care services demonstrates advocating for the client's best interest, ensuring they receive appropriate care to manage symptoms and improve quality of life. This action aligns with the nurse's role as a client advocate by advocating for the client's autonomy and well-being. In contrast, choices A, C, and D do not prioritize the client's best interests or rights.
Choice A disregards the client's autonomy by encouraging medication against their wishes.
Choice C prioritizes hospital efficiency over the client's needs.
Choice D violates the client's right to informed decision-making by withholding essential information. Overall, choice B best exemplifies client advocacy in nursing practice.
Question 5 of 5
A nurse is assessing a client who recently had a myocardial infarction. Which of the following findings indicates that the client might be developing pulmonary edema? (Select all that apply.)
Correct Answer: A, C, D
Rationale: The correct answers are A, C, and D. Excessive somnolence (
A) can indicate inadequate oxygenation due to pulmonary edema. Pink frothy sputum (
C) is a classic sign of pulmonary edema, caused by fluid leaking into the lungs. Tachypnea (
D) is the body's response to decreased oxygen levels in the blood, characteristic of pulmonary edema. Epistaxis (
B) and urinary frequency (E) are not typically associated with pulmonary edema. In summary, the correct answers reflect respiratory distress and inadequate oxygenation, while the incorrect choices are unrelated symptoms.