ATI RN
RN ATI Adult Medsurg Proctored Exam 2023 With NGN Questions
Extract:
Question 1 of 5
A nurse is assessing a clients ECG strip and notes an irregular heart rate of 98/min with no clear P waves. Which of the following cardiac dysrhythmias should the nurse document?
Correct Answer: B
Rationale: The correct answer is B: Atrial fibrillation. In atrial fibrillation, the heart rate is irregular and fast (98/min), and there are no clear P waves on the ECG strip, which aligns with the findings in the scenario. Atrial fibrillation is characterized by chaotic electrical activity in the atria, leading to an irregular heart rate. Sinus bradycardia (
A) is characterized by a slow heart rate with normal P waves. Ventricular tachycardia (
C) is a fast heart rhythm originating in the ventricles with distinct QRS complexes. First-degree heart block (
D) is identified by a prolonged PR interval but should still have clear P waves. Other choices are not relevant. In this case, the absence of clear P waves and irregular heart rate point towards atrial fibrillation as the correct dysrhythmia to document.
Question 2 of 5
A nurse is caring for a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Report cloudy dialysate drainage to the provider. Cloudy dialysate drainage can indicate infection, leading to peritonitis. The nurse should report this immediately for further evaluation and treatment to prevent complications. Lowering the drainage bag below the abdomen (
B) can cause backflow, increasing the risk of contamination. Encouraging fluid intake of 3L per day (
C) is a general recommendation but not specific to peritoneal dialysis. Using sterile gloves only when removing the catheter (
D) is incorrect as sterile technique is required during all catheter manipulations in peritoneal dialysis.
Question 3 of 5
A nurse is assessing a client who has suspected appendicitis. Which of the following manifestations should the nurse expect? (Select all that apply.)
Correct Answer: A, B, C
Rationale: The correct manifestations for suspected appendicitis are A, B, and C. A is correct as appendicitis typically presents with right lower quadrant pain due to inflammation of the appendix. B is correct as rebound tenderness, which is pain upon release of pressure on the abdomen, is a classic sign of appendicitis. C is correct as nausea and vomiting are common symptoms due to irritation of the gastrointestinal tract. D and E are incorrect as elevated blood glucose and hypotension are not commonly associated with appendicitis.
Question 4 of 5
A nurse is planning preventative strategies for a client who is at risk for pressure injuries. Which of the following actions should the nurse include in the plan?
Correct Answer: A
Rationale: The correct answer is A: Apply moisturizer to damp skin after bathing. Moisturizing helps maintain skin integrity and hydration, reducing the risk of pressure injuries. When skin is damp, it is more receptive to hydration, which can prevent dryness and breakdown. Applying moisturizer also helps to maintain the skin's natural barrier function. Massaging bony prominences (choice
B) can actually increase the risk of pressure injuries by causing friction and shearing forces. Using cornstarch powder (choice
C) can lead to moisture buildup and increase the risk of skin breakdown. Positioning the client at a 90-degree angle in bed (choice
D) is not a recommended preventive strategy for pressure injuries.
Question 5 of 5
A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following findings should the nurse identify as a manifestation of type 1 diabetes?
Correct Answer: A
Rationale: The correct answer is A: Ketones in the urine. In type 1 diabetes, the body cannot produce insulin, leading to high blood sugar levels and breakdown of fats for energy, resulting in ketones in the urine. Weight gain (
B) is unlikely as type 1 diabetes is associated with weight loss. Hypotension (
C) is not a typical manifestation. Decreased hunger (
D) is more commonly seen in type 2 diabetes.