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 developed acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse identify as a manifestation of this syndrome?
Correct Answer: B
Rationale:
Correct
Answer: B - Refractory hypoxemia.
Rationale: ARDS is characterized by severe hypoxemia that persists despite high levels of oxygen therapy, known as refractory hypoxemia. This occurs due to ventilation-perfusion mismatch and impaired gas exchange in the alveoli. The other choices are not typical manifestations of ARDS:
A: Bronchoconstriction is more commonly seen in asthma or COPD.
C: Pulmonary hypertension may develop as a complication of ARDS but is not a direct manifestation.
D: Pleural effusion may occur in ARDS but is not a defining characteristic.
Question 2 of 5
An emergency room nurse is assessing a client who has asthma and difficulty breathing. Which of the following findings should indicate to the nurse that the client is experiencing status asthmaticus?
Correct Answer: B
Rationale: The correct answer is B: Use of accessory muscles. In status asthmaticus, a severe and life-threatening asthma exacerbation, the client's airways are severely constricted, leading to inadequate air exchange. The use of accessory muscles (such as intercostal and supraclavicular muscles) indicates significant respiratory distress as the body tries to compensate for the difficulty in breathing. Mild wheezing (choice
A) may be present in asthma but does not necessarily indicate status asthmaticus. Decreased respiratory rate (choice
C) is not consistent with the increased respiratory effort seen in status asthmaticus. Productive cough (choice
D) is more indicative of conditions such as bronchitis or pneumonia, not necessarily status asthmaticus.
Question 3 of 5
A nurse is teaching a client who has a new prescription for phenytoin to treat a seizure disorder. Which of the following adverse effects should the nurse instruct the client to report immediately to the provider?
Correct Answer: C
Rationale: The correct answer is C: Skin rash. This is because phenytoin can cause severe and potentially life-threatening skin reactions like Stevens-Johnson syndrome or toxic epidermal necrolysis. These reactions can progress rapidly, so immediate medical attention is crucial. Drowsiness (
A) is a common side effect of phenytoin but not typically an emergency. Gingival hyperplasia (
B) and mild nausea (
D) are common side effects that do not require immediate reporting.
Question 4 of 5
A nurse is monitoring a client following a lumbar laminectomy. The client has a drain and indwelling urinary catheter. The nurse should identify which of the following findings as an indication of a complication of the surgery?
Correct Answer: C
Rationale: The correct answer is C: Clear drainage on the dressings. Clear drainage may indicate a cerebrospinal fluid leak, which is a serious complication following a lumbar laminectomy. Cerebrospinal fluid is a clear fluid that surrounds the brain and spinal cord, and its leakage can lead to infection and other complications. Red-tinged drainage (choice
A) may be expected initially due to surgical trauma. Cloudy urine in the catheter (choice
B) is more likely related to urinary tract infection. Mild back pain at the surgical site (choice
D) is common after this surgery and does not necessarily indicate a complication.
Question 5 of 5
A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse identify as a manifestation of right-sided heart failure?
Correct Answer: B
Rationale: The correct answer is B: Increased abdominal girth. In right-sided heart failure, the heart is unable to efficiently pump blood to the lungs for oxygenation, leading to fluid backup in the systemic circulation. This results in fluid retention, particularly in the abdomen, causing increased abdominal girth. Crackles in the lungs (choice
A) are indicative of left-sided heart failure. Pink frothy sputum (choice
C) is a sign of pulmonary edema, which is a manifestation of left-sided heart failure. Hypertension (choice
D) is not typically associated with right-sided heart failure.