ATI RN
ATI RN Adult Medical Surgical 2023 Questions Questions
Extract:
Question 1 of 5
A nurse is assessing a client who is taking telmisartan. The nurse should identify that which of the following findings indicates that the medication has been effective?
Correct Answer: B
Rationale: The correct answer is B: Decrease in blood pressure. Telmisartan is an angiotensin II receptor blocker used to treat hypertension. A decrease in blood pressure indicates that the medication is effective in controlling hypertension. This is the desired outcome of telmisartan therapy as it helps reduce the risk of cardiovascular events.
Choices A, C, and D are not directly related to the effectiveness of telmisartan. Blood glucose level and urinary output are not typically influenced by telmisartan, and respiratory rate is not a primary indicator of its effectiveness.
Therefore, the most appropriate indicator of telmisartan's effectiveness in this scenario is a decrease in blood pressure.
Question 2 of 5
A nurse is assessing a client who is postoperative following an open reduction and internal fixation (ORIF) of the femur. Which of the following assessments should be the nurse's priority?
Correct Answer: A
Rationale: The correct answer is A: Neurovascular assessment. This is the priority because the client is postoperative following ORIF of the femur, which puts them at risk for impaired circulation and nerve damage. The nurse needs to assess for signs of compromised blood flow or nerve function, such as changes in sensation, color, temperature, or pulse in the affected limb. If left unaddressed, neurovascular complications can lead to serious consequences like compartment syndrome or permanent damage. The other options are not the priority in this situation: B (Braden scale) assesses risk for pressure ulcers, C (Pain assessment) is important but not the priority over neurovascular status, and D (Morse Fall Risk scale) assesses fall risk which is important but not the priority immediately post-ORIF.
Question 3 of 5
A nurse is caring for a client who is 3 hr postoperative following a total knee arthroplasty. Which of the following actions should the nurse take to prevent venous thromboembolism?
Correct Answer: A
Rationale:
Correct
Answer: A - Encourage the client to perform circumduction of the feet.
Rationale: Circumduction of the feet involves moving the feet in a circular motion, which helps promote blood circulation and prevent stasis in the lower extremities. This movement aids in preventing venous thromboembolism by reducing the risk of blood clots forming in the legs postoperatively. Encouraging this activity is crucial in maintaining vascular health and preventing complications.
Summary of Incorrect
Choices:
B: Keeping the client's knees in a flexed position while in bed may lead to decreased circulation and increase the risk of venous stasis.
C: Massaging the client's legs every 4 hours can dislodge blood clots and increase the risk of embolism.
D: Limiting fluid intake can lead to dehydration, which can increase the risk of clot formation due to thicker blood consistency.
Question 4 of 5
A nurse is caring for a client who requires protective isolation following a hematopoietic stem cell transplant. Which of the following interventions should the nurse implement to protect the client from infection?
Correct Answer: A
Rationale:
Correct
Answer: A: Make sure the client's room has positive pressure airflow.
Rationale:
1. Positive pressure airflow prevents contaminated air from entering the room, reducing the risk of infections.
2. It helps maintain a clean environment by keeping airborne pathogens out.
3. Protects the client who has a compromised immune system post-transplant.
Summary of Incorrect
Choices:
B: Disposable utensils are important but do not directly protect the client from airborne infections.
C: N95 respirators are for the healthcare provider's protection, not the client's.
D: Monitoring temperature is essential but does not directly prevent infections in a protective isolation setting.
Question 5 of 5
A nurse is caring for a client who has left-sided heart failure. Which of the following manifestations should the nurse expect?
Correct Answer: C
Rationale: The correct answer is C: Dyspnea. Left-sided heart failure typically results in pulmonary congestion, leading to symptoms like dyspnea due to fluid accumulation in the lungs. Pedal edema (
A) is more common in right-sided heart failure. Enlarged liver (
B) is a sign of right-sided heart failure as well. Neck vein distention (
D) is indicative of right-sided heart failure due to increased right atrial pressure. The focus in left-sided heart failure is on pulmonary symptoms, making dyspnea the most relevant manifestation.