ATI RN
ATI Medsurg Proctored Final Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who was admitted with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Provide frequent oral and nares care. This is important because the Sengstaken-Blakemore tube can cause discomfort and irritation to the oral and nasal mucosa, leading to potential complications such as infection or pressure ulcers. Providing frequent oral and nares care helps prevent these complications and ensures the client's comfort.
Choice B is incorrect because monitoring oxygen levels is not directly related to the care of a client with a Sengstaken-Blakemore tube.
Choice C is incorrect because administering intravenous antibiotics is not a routine intervention for a client with a Sengstaken-Blakemore tube unless there is a specific indication for infection.
Choice D is incorrect because the Sengstaken-Blakemore tube should not be removed immediately after 24 hours. The timing of removal should be determined based on the client's condition and the healthcare provider's orders.
Question 2 of 5
A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications should the nurse identify as most important for the client's recovery?
Correct Answer: A
Rationale: The correct answer is A: It facilitates the client's deep breathing. Postoperative clients following CABG surgery are at risk for developing atelectasis due to decreased lung expansion. Opioid medications can cause respiratory depression, leading to shallow breathing. By facilitating deep breathing, the nurse helps prevent atelectasis and promotes optimal oxygenation, aiding in the client's recovery.
Choices B, C, and D are incorrect as they are not directly related to the immediate physiological needs of a postoperative CABG client. Increasing appetite, promoting wound healing, and decreasing anxiety are important aspects of overall recovery but are not as critical as ensuring proper oxygenation and preventing respiratory complications in the immediate postoperative period.
Question 3 of 5
A nurse is presenting a community-based program about HIV and AIDS. A client asks the nurse to describe the initial symptoms experienced with HIV infection. Which of the following manifestations should the nurse include in the explanation of initial symptoms?
Correct Answer: C
Rationale: The correct answer is C: Flu-like symptoms and night sweats. Initial symptoms of HIV infection often resemble flu-like symptoms such as fever, fatigue, sore throat, swollen lymph nodes, and night sweats. This occurs because the virus is rapidly replicating in the body and the immune system is reacting to it. The other choices, abdominal cramps and diarrhea (
A), persistent cough and chest pain (
B), and severe fatigue and weight loss (
D), are more commonly associated with later stages of HIV infection or other conditions.
Therefore, the nurse should include flu-like symptoms and night sweats in the explanation of initial symptoms to accurately inform the client.
Question 4 of 5
A nurse is implementing a plan of care for a client who has AIDS with recurring pneumonia. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Obtain a sputum culture. This is essential to identify the specific pathogen causing the pneumonia in the client with AIDS. By identifying the pathogen, appropriate antibiotic therapy can be initiated promptly. Administering a chest X-ray (
B) may help in evaluating the extent of pneumonia but does not address the underlying cause. Monitoring for fever (
C) is important but does not provide specific information needed for targeted treatment. Providing oxygen therapy (
D) may be necessary but does not address the root cause of the pneumonia.
Question 5 of 5
A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction?
Correct Answer: A
Rationale: The correct answer is A: Perform a 12-lead ECG. This is because an ECG is the most reliable and direct way to assess for myocardial infarction by identifying characteristic changes in the heart's electrical activity. Nitroglycerin (
B) is used to relieve chest pain but should not be administered before confirming the diagnosis. Placing the client in a prone position (
C) is not appropriate for assessing chest pain. Assessing blood pressure (
D) is important but not the initial priority when suspecting myocardial infarction.