ATI RN
ATI RN Adult Medical Surgical 2023 Questions Correct Answers Questions
Extract:
Exhibit 1- Medical History,
Dehydration, Hyperlipidemia, Hypertension, Coronary artery disease (CAD) Exhibit 2-
Diagnostic Results
WBC count 14,000/mm° (5,000 to 10,000/mm)
Hgb 14 g/dL (12 to 16 g/dL)
Hct 40% (34 to 47%)
Sodium 132 mEq/L (136 to 146 mEq/L)
Potassium 6.2 mEq/L (3.5 to 5 mEq/L)
Question 1 of 5
A nurse is caring for a client receiving TPN. Which of the following actions should the nurse take? For each potential nursing intervention, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client.
| Nursing Intervention | Anticipated | Non-essential | Contraindicated |
|---|---|---|---|
| Request a prescription for insulin | |||
| Request for an antibitic to be administered | |||
| Decrease the client's oxygen to 1.5 L/min via nasal canula | |||
| Have 3 nurses verify the TPN solution prescription | |||
| Notify the provider to increase TPN rate/hr |
Correct Answer: A,B,C,D
Rationale: [
Anticipated: Request a prescription for insulin, Request for an antibiotic to be administered, Decrease the client's oxygen to 1.5 L/min via nasal cannula, Have 3 nurses verify the TPN solution prescription.
Rationale: A client on TPN may require insulin for glycemic control, antibiotics for infection management, oxygen adjustment for respiratory support, and verification of TPN solution to prevent errors.
Non-essential/Contraindicated: Not applicable as all options are essential in the care of a client receiving TPN.]
Extract:
Question 2 of 5
A nurse is caring for a client who has acute angina. Which of the following actions should the nurse take first?
Correct Answer: B
Rationale: The correct answer is B: Administer aspirin. Administering aspirin is the priority action for a client with acute angina as it helps in reducing platelet aggregation and improving blood flow to the heart. This action can potentially prevent further clot formation and decrease the risk of a heart attack. It is essential to address the acute symptoms first before proceeding with other interventions. Measuring blood pressure (
A), administering nitroglycerin (
C), and initiating IV access (
D) are important actions but administering aspirin takes precedence in this scenario to address the acute angina symptoms promptly.
Question 3 of 5
A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes that the weights are resting on the floor. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Reapply the weights to ensure proper traction. When the weights are resting on the floor, it means that there is no longer effective traction on the affected limb.
To maintain proper skeletal traction, the weights should be suspended freely in the air. By reapplying the weights and ensuring they are hanging freely, the nurse can restore the necessary traction force to immobilize the fractured bone and facilitate healing. Removing a weight (choice
A) may compromise the traction. Tying knots in the ropes (choice
B) may alter the mechanics of the traction system. Increasing the elevation of the extremity (choice
C) does not address the issue of the weights resting on the floor.
Question 4 of 5
A nurse is caring for a client who is receiving morphine through a PCA device. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A. Teaching the client how to self-medicate using the PCA device is essential to empower the client in managing their pain effectively. This promotes autonomy and ensures the client receives the appropriate dose at the right time, enhancing pain control.
Choice B is incorrect as family members should not press the PCA button for the client to maintain safety and prevent medication errors.
Choice C is incorrect as respiratory status should be monitored more frequently, ideally every 1-2 hours, when a client is receiving opioids due to the risk of respiratory depression.
Choice D is incorrect as administering an oral opioid for breakthrough pain may lead to overdose or adverse effects when already receiving morphine through PCA.
Question 5 of 5
A nurse is providing dietary instructions to a client who has cardiovascular disease. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: C
Rationale: The correct answer is C: "I will use canola oil when making salad dressing." Canola oil is a healthier choice than other oils, as it is low in saturated fats and high in monounsaturated fats, which are beneficial for cardiovascular health. Using canola oil in salad dressing can help decrease the intake of unhealthy fats.
Choice A is incorrect because limiting meat portions alone may not address overall dietary fat intake.
Choice B is incorrect as canned vegetables may contain added sodium, which is not ideal for cardiovascular health.
Choice D is incorrect as whole milk is high in saturated fats, not recommended for cardiovascular disease.