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 deep-vein thrombosis and is receiving heparin via continuous IV infusion. The clients weight is 80 kg (176.4 lb). Using the client information provided, which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Stop the heparin infusion for 1 hr. This is because the client's weight is crucial in determining the appropriate heparin dosage. Heparin is usually dosed based on the client's weight to prevent complications such as bleeding or clotting. In this case, the client's weight of 80 kg indicates a specific dose range for heparin. Stopping the infusion for 1 hour allows the nurse to reassess the client's condition and potentially adjust the heparin dosage to ensure it is safe and effective.
A: Increasing the infusion rate without proper assessment can lead to overdose and increased risk of bleeding.
B: Administering protamine sulfate is the antidote for heparin overdose, not indicated in this scenario.
D: Decreasing the heparin dose without assessment may result in inadequate anticoagulation and increased risk of clot formation.
Question 2 of 5
A nurse is caring for a client who is intubated and receiving mechanical ventilation for heroin toxicity. Which of the following assessments is the nurses priority?
Correct Answer: C
Rationale: The correct answer is C: Check ABGs. In this scenario, monitoring the client's arterial blood gases (ABGs) is the priority assessment because heroin toxicity can lead to respiratory depression and impaired gas exchange. ABGs provide crucial information about the client's oxygenation and ventilation status, which is essential for managing mechanical ventilation and preventing respiratory complications. Monitoring urine output (
A) is important but not the priority in a client with potential respiratory compromise. Assessing level of consciousness (
B) is significant, but ensuring adequate oxygenation takes precedence. Monitoring for signs of withdrawal (
D) is important but not as urgent as assessing respiratory status.
Question 3 of 5
A nurse is assessing a client who has a new diagnosis of pericarditis. Which of the following findings should the nurse identify as a manifestation of cardiac tamponade?
Correct Answer: B
Rationale: The correct answer is B: Jugular vein distention. In cardiac tamponade, fluid accumulates in the pericardial sac, compressing the heart. This leads to increased pressure in the heart chambers, causing jugular vein distention due to impaired venous return. A: Atrial fibrillation is a common arrhythmia but not specific to cardiac tamponade. C: Bradycardia is not a typical finding in cardiac tamponade as the body tries to compensate for decreased cardiac output. D: Hypotension can be present but is a late sign and not specific to cardiac tamponade.
Question 4 of 5
A nurse is assessing a client who is undergoing radiation therapy for breast cancer. Which of the following findings is an indication to the nurse that the client is experiencing an adverse effect of the therapy?
Correct Answer: A
Rationale: The correct answer is A: Skin changes. This is because skin changes, such as redness, irritation, or peeling, are common adverse effects of radiation therapy. The skin over the treated area may become sensitive and may develop a sunburn-like appearance. This indicates that the radiation is affecting the skin cells. Hypertension (
B), diarrhea (
C), and increased white blood cell count (
D) are not typically associated with adverse effects of radiation therapy for breast cancer. Hypertension may be related to stress or other factors, diarrhea could be due to other causes, and an increased white blood cell count is not a typical adverse effect of radiation therapy.
Question 5 of 5
A nurse is preparing to administer enoxaparin 0.75 mg/kg subcutaneously to a client who weighs 154 lb. The amount available is enoxaparin 60 mg/0.6 mL. How many mL should the nurse administer?
Correct Answer: B
Rationale:
To calculate the dose of enoxaparin, first convert the client's weight from pounds to kilograms: 154 lb/2.2 = 70 kg.
Then, calculate the dose: 0.75 mg/kg x 70 kg = 52.5 mg. Since the concentration is 60 mg/0.6 mL, divide the dose needed by the concentration: 52.5 mg/60 mg x 0.6 mL = 0.5 mL.
Therefore, the correct answer is B (0.5 mL).
Choice A is incorrect as it is less than the calculated dose.
Choice C is incorrect as it is based on the concentration but does not match the calculated dose.
Choice D is incorrect as it is higher than the calculated dose.