ATI RN
ATI RN Adult Medical Surgical 2023 Questions Correct Answers Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is experiencing diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse?
Correct Answer: D
Rationale: The correct answer is D: Administer 0.9% sodium chloride. The priority intervention in DKA is fluid resuscitation to correct dehydration and electrolyte imbalances. 0.9% sodium chloride helps restore intravascular volume and improves kidney perfusion. Checking potassium levels (
A) is important but can wait until after fluid resuscitation. Beginning bicarbonate infusion (
B) is not recommended as it can worsen acidosis. Initiating continuous IV insulin infusion (
C) is important but should follow fluid resuscitation. Administering 0.9% sodium chloride takes precedence in managing DKA.
Question 2 of 5
A nurse is assessing a client who has a pressure injury. Which of the following findings should the nurse expect as an indication the wound is healing?
Correct Answer: D
Rationale: The correct answer is D: Dark red granulation tissue. Granulation tissue is a sign of healing in a wound, indicating new blood vessels and collagen formation. Dark red color indicates good blood supply. A: Firm wound tissue can indicate infection or inadequate healing. B: Dry brown eschar is a sign of necrotic tissue, not healing. C: Light yellow exudate can indicate infection or inflammation.
Question 3 of 5
A nurse is providing instructions about foot care for a client who has peripheral arterial disease. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: A
Rationale: The correct answer is A because applying a lubricating lotion to the cracked areas on the soles of the feet helps prevent further skin breakdown and infection, which is crucial in peripheral arterial disease.
Choice B may improve circulation, but it does not address foot care directly.
Choice C can lead to burns or injury due to decreased sensation in peripheral arterial disease.
Choice D poses a risk of injury or infection due to the potential for skin damage while soaking the feet. Overall, choice A is the most appropriate for maintaining foot health in peripheral arterial disease.
Question 4 of 5
A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg, a fluid intake of 960 mL, and an output of 300 mL in the past 12 hr. Which of the following actions should the nurse take?
Correct Answer: C
Rationale:
Correct
Answer: C - Slow infusion rate and contact the provider.
Rationale: The client is showing signs of fluid volume overload with dyspnea, elevated blood pressure, and a significant fluid intake-output discrepancy. Slowing the infusion rate will help reduce fluid intake and potentially prevent worsening of the overload. Contacting the provider is crucial for further assessment and possible adjustment of the treatment plan.
Summary:
A: Lowering the head of the bed may help with respiratory distress but does not address the underlying issue of fluid overload.
B: Administering corticosteroids is not indicated for fluid overload and may worsen the situation.
D: Changing to lactated Ringer's does not address the immediate need to slow down the infusion rate and seek provider guidance.
Question 5 of 5
A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct action to take first when caring for a client experiencing a seizure is to clear items from the client's surrounding area (
Choice
D). This is important to prevent injury to the client during the seizure. By removing objects that could cause harm, such as sharp or hard items, the nurse ensures a safe environment for the client. Lowering the client to the floor (
Choice
A) is important but should be done after clearing the surroundings to prevent injury. Obtaining vital signs (
Choice
B) and loosening restrictive clothing (
Choice
C) can be done after ensuring the safety of the environment. Thus, the priority is to clear items from the client's surrounding area to prevent harm during the seizure.