ATI RN
RN ATI Adult Medsurg Proctored Exam 2023 With NGN Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has chronic venous insufficiency. Which of the following areas should the nurse assess for the presence of a venous ulcer?
Correct Answer: B
Rationale: The correct answer is B: Medial malleolus (ankle). Venous ulcers commonly occur in areas where there is poor circulation, such as the lower legs. The medial malleolus is a common site for venous ulcers in individuals with chronic venous insufficiency due to pooling of blood in the lower extremities. Assessing this area is crucial for early detection and appropriate management.
Choices A, C, and D are incorrect as venous ulcers typically develop in areas with high venous pressure and poor circulation, such as the lower legs, not at the tip of the toes, ball of the foot, or heel.
Question 2 of 5
A nurse in an emergency department is caring for a client who is confused, has a temperature of 40° C (104° F), a BP of 74/52 mm Hg, and a diagnosis of exertional heat stroke. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen using a high-concentration mask. In exertional heat stroke, the body's ability to regulate temperature is compromised, leading to confusion, high temperature, and low blood pressure. Oxygen therapy helps support oxygenation during heat stress. It takes priority to ensure adequate oxygenation and prevent hypoxia, which can worsen the client's condition.
Choices B, C, and D are incorrect. Giving cold fluids orally can potentially induce shock in a hypotensive client. Applying a heating pad can lead to further increase in body temperature. Encouraging the client to walk can exacerbate heat stress and increase the risk of collapse.
Question 3 of 5
A nurse is caring for a client who has a prescription for lactated Ringers by continuous IV infusion to replace output from an NG tube. Which of the following findings should indicate to the nurse that this therapy is effective?
Correct Answer: B
Rationale: The correct answer is B: Urine specific gravity 1.020. This finding indicates that the kidneys are effectively concentrating urine, which means fluid balance is being maintained. A specific gravity of 1.020 is within the normal range, suggesting adequate hydration. A high specific gravity like 1.035 (choice
A) indicates dehydration. Decreased skin turgor (choice
C) and dry mucous membranes (choice
D) are signs of dehydration, not effectiveness of therapy.
Question 4 of 5
A nurse is caring for a client who is 3 hr postoperative and exhibiting signs of hypovolemia. Which of the following findings should the nurse identify as a manifestation of hypovolemia?
Correct Answer: A
Rationale: The correct answer is A: Rapid pulse rate. Following surgery, hypovolemia can occur due to fluid loss. A rapid pulse rate is a common manifestation of hypovolemia as the body compensates for decreased blood volume by increasing heart rate to maintain perfusion. Bradycardia (
B) is unlikely with hypovolemia as the body tries to increase cardiac output. Hypertension (
C) is not typical in hypovolemia as blood pressure tends to decrease. Peripheral edema (
D) is associated with fluid overload, not hypovolemia.
Question 5 of 5
A nurse is planning care for a client who has tuberculosis. Which of the following precautions should the nurse implement for this client?
Correct Answer: B
Rationale: The correct answer is B: Airborne precautions. Tuberculosis is spread through the air via droplet nuclei. Implementing airborne precautions involves placing the client in a negative pressure room, using an N95 respirator, and ensuring proper ventilation. Standard precautions (
A) are used for all clients. Contact precautions (
C) are used for clients with infections that can be spread by direct or indirect contact. Droplet precautions (
D) are used for infections spread through larger respiratory droplets. In this case, airborne precautions are specifically needed due to the mode of transmission of tuberculosis.