ATI RN
ATI RN Adult Medical Surgical 2023 Questions Correct Answers Questions
Extract:
Question 1 of 5
A nurse is assessing a client who has increased intracranial pressure. The nurse should recognize that which of the following is the first sign of deteriorating neurological status?
Correct Answer: A
Rationale: The correct answer is A: Altered level of consciousness. This is the first sign of deteriorating neurological status in a client with increased intracranial pressure. Changes in consciousness indicate impairment in brain function, signaling potential brain injury or worsening condition. Altered level of consciousness can progress rapidly if not addressed promptly.
Choice B, Cheyne-Stokes respirations, is associated with abnormal breathing patterns and typically occurs in conditions like heart failure or brain injury, but it is not the first sign of neurological deterioration.
Choice C, Decorticate posturing, is a sign of brain injury but typically occurs after alterations in consciousness.
Choice D, pupillary dilation, can be a sign of increased intracranial pressure, but it usually occurs after alterations in consciousness.
Question 2 of 5
A nurse is teaching a client who has Graves' disease about recognizing the manifestations of thyroid storm. Which of the following findings should the nurse include in the teaching?
Correct Answer: D
Rationale: The correct answer is D: Increased temperature. In thyroid storm, there is excessive thyroid hormone production leading to hyperthyroidism symptoms, including increased body temperature. Lethargy (
A) is more indicative of hypothyroidism. Hypotension (
B) is not a typical finding in thyroid storm; instead, hypertension is more common. Decreased heart rate (
C) is also not a common manifestation as tachycardia is typically present in thyroid storm.
Therefore, option D is the most appropriate manifestation to recognize in thyroid storm.
Question 3 of 5
A nurse is caring for a client who has a chest tube. The client asks why the fluid in the water-seal chamber rises and falls. Which of the following statements should the nurse make?
Correct Answer: A
Rationale: The correct answer is A: "Your breathing pattern causes this." The fluctuation in the fluid level of the water-seal chamber of a chest tube system is directly related to changes in intrathoracic pressure during breathing. As the client breathes in and out, the negative pressure in the pleural space increases and decreases, causing the fluid to rise and fall in the water-seal chamber. This movement is a normal physiological response and indicates proper functioning of the chest tube system.
Choices B, C, and D are incorrect because they do not accurately explain the reason for the fluid fluctuation in the water-seal chamber.
Choice B is incorrect as lung re-expansion does not directly cause the fluid movement.
Choice C is incorrect as high suction pressure does not cause this specific phenomenon.
Choice D is incorrect as fluid movement does not indicate an air leak.
Question 4 of 5
A nurse is caring for a group of clients who are 12 hr postoperative. The nurse should identify that the client who had which of the following procedures is at risk for developing fat embolism syndrome?
Correct Answer: C
Rationale: The correct answer is C: Internal fixation of a fractured hip. Fat embolism syndrome (FES) typically occurs in long bone fractures or orthopedic surgeries like hip fixation due to fat droplets entering the bloodstream. These fat droplets can travel to the lungs, brain, and other organs, causing respiratory distress, neurological symptoms, and petechial rash. In contrast, choices A, B, and D are not associated with a high risk of FES. Thyroidectomy involves removal of the thyroid gland, repair of torn rotator cuff involves shoulder surgery, and tympanoplasty involves repairing the eardrum, none of which typically lead to fat embolism.
Question 5 of 5
A nurse manager is providing an in-service to a group of newly licensed nurses about the use of personal protective equipment. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?
Correct Answer: C
Rationale: The correct answer is C: "I should wear goggles when irrigating a wound." This indicates an understanding of the teaching as goggles protect the eyes from splashes and sprays. Wearing goggles during wound irrigation helps prevent potential eye exposure to contaminated fluids, reducing the risk of infection.
Choice A is incorrect because wearing a gown to remove linens is unnecessary for personal protective equipment during this task.
Choice B is incorrect as sterile gloves are required for clean procedures like wound care, not for administering IM injections.
Choice D is incorrect because using both hands to recap a needle increases the risk of needle-stick injuries.