ATI RN
RN ATI Adult Medsurg Proctored Exam 2023 With NGN Questions
Extract:
Question 1 of 5
A nurse is monitoring a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a manifestation of Cushings triad?
Correct Answer: A
Rationale: The correct answer is A: Increase in blood pressure from 130/80 mm Hg to 180/100 mm Hg. Cushing's triad is a classic sign of increased intracranial pressure (ICP), seen in traumatic brain injury. It consists of hypertension (elevated blood pressure), bradycardia (not tachycardia), and irregular respirations (not rapid shallow respirations). The increase in blood pressure is due to the body's attempt to maintain cerebral perfusion in response to the increased ICP. The other choices are incorrect because they do not align with the classic presentation of Cushing's triad in traumatic brain injury.
Question 2 of 5
A nurse is preparing to administer potassium chloride 10 mEq IV over 1 hr to a client. Available is potassium chloride 10 mEq in 100 mL of 0.9% sodium chloride. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number.)
Correct Answer: C
Rationale:
To calculate the infusion rate, we need to use the formula: (Desired dose ÷ Volume) x 60 minutes. In this case, the desired dose is 10 mEq over 1 hour, and the volume is 100 mL.
So, (10 ÷ 100) x 60 = 6 mL/hr.
Therefore, the nurse should set the infusion pump to deliver 100 mL/hr. This ensures the correct administration of potassium chloride over the specified time frame.
Choice A (50 mL/hr) and B (75 mL/hr) are incorrect as they would result in the underdosing of potassium chloride.
Choice D (125 mL/hr) is incorrect as it would result in the overdosing of potassium chloride. The correct answer, C (100 mL/hr), ensures the proper administration of the medication within the specified parameters.
Question 3 of 5
A nurse is providing teaching about dietary options for a client who has cholelithiasis. Which of the following statements should the nurse include in the teaching?
Correct Answer: A
Rationale: The correct answer is A: Avoid high-fat cuts of meat. Cholelithiasis is the formation of gallstones, often related to high-fat diets. High-fat cuts of meat can trigger gallbladder contractions, leading to pain. The rationale is to reduce fat intake to prevent further gallstone formation.
Choices B, C, and D are incorrect. B: Increasing fried foods can exacerbate symptoms due to their high-fat content. C: Consuming dairy products at every meal is not recommended as some dairy products can be high in saturated fats. D: Eating large meals can overload the digestive system, potentially leading to gallbladder discomfort.
Question 4 of 5
A nurse is providing discharge teaching to a client who has COPD. Which of the following instructions should the nurse include in the teaching?
Correct Answer: A
Rationale:
Rationale: A client with COPD often has increased energy needs due to the work of breathing. Consuming a high-calorie diet helps meet these needs. This can prevent malnutrition and promote optimal energy levels. Limiting fluid intake (
B) can lead to dehydration and thicker mucus. Strenuous exercise (
C) may exacerbate breathing difficulties. Reducing carbohydrate intake (
D) can lead to decreased energy levels.
Question 5 of 5
A nurse is assessing a clients understanding of a surgical procedure prior to witnessing their signature on the informed consent form. The nurse determines that the client does not understand what the procedure will involve. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Contact the provider who will be performing the procedure. This is the best course of action because the provider is the most qualified individual to explain the procedure in detail and address any concerns the client may have. By involving the provider, the client can receive accurate and comprehensive information directly from the source. Proceeding with obtaining the signature (
A) without ensuring the client's understanding can lead to potential legal and ethical issues. Explaining the procedure in detail (
B) may not be sufficient if the client still has questions or concerns. Having the client sign the form and addressing concerns later (
D) is not appropriate as it prioritizes paperwork over patient understanding and safety.