ATI RN
ATI RN Adult Medical Surgical 2023 Questions Correct Answers Questions
Extract:
Question 1 of 5
A nurse is preparing to administer propranolol to several clients. For which of the following clients should the nurse clarify the prescription with the provider before administration?
Correct Answer: A
Rationale: The correct answer is A: A client who has a history of asthma. Propranolol is a non-selective beta-blocker that can potentially cause bronchoconstriction in clients with asthma due to its beta-2 antagonistic effects. The nurse should clarify the prescription with the provider for this client to avoid exacerbating respiratory issues.
Choices B, C, and D are not contraindications for propranolol administration, as hypertension, migraines, and stable angina are conditions that can be treated with beta-blockers. It is important for the nurse to assess each client's medical history and consider potential contraindications before administering medications to ensure client safety and optimal outcomes.
Question 2 of 5
A nurse is assessing a client who has a chest tube connected to a closed water-seal drainage system. Which of the following findings should the nurse report to the provider?
Correct Answer: A
Rationale: The correct answer is A: Constant bubbling in the water seal chamber. Constant bubbling in the water seal chamber indicates an air leak in the chest tube system, which can lead to lung collapse or pneumothorax. This finding should be reported to the provider immediately for further evaluation and intervention. Intermittent bubbling in the suction chamber (choice
B) is expected and indicates that the suction is working properly. Clear drainage of 50 mL over 8 hours (choice
C) is within normal limits and does not require immediate reporting. Mild pain at the insertion site (choice
D) is common after a chest tube insertion and can be managed with pain medication.
Question 3 of 5
A nurse is caring for a client who has a small bowel obstruction and an NG tube in place. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Maintain low intermittent suction. This is because in a small bowel obstruction, the NG tube helps decompress the bowel by removing gastric contents and relieving pressure. Low intermittent suction helps prevent excessive suction which can cause tissue damage.
Clamping the NG tube every 2 hours (choice
B) is incorrect as it will prevent the tube from effectively decompressing the bowel. Removing the NG tube immediately (choice
C) is also incorrect as it is needed for decompression. Encouraging high-fiber foods (choice
D) is contraindicated as they can worsen the obstruction.
Question 4 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 Cushing's 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 set of three classic signs indicating increased intracranial pressure (ICP). The triad includes hypertension (widening pulse pressure), bradycardia, and irregular respirations. In this case, an increase in blood pressure is consistent with the hypertension component of Cushing's triad. This occurs due to the body's compensatory mechanism to maintain perfusion to the brain in response to increased ICP.
Choices B, C, D, and E do not align with the classic signs of Cushing's triad. Bradycardia, not a decrease in heart rate, is typically seen in Cushing's triad. Rapid and shallow respirations are not part of the triad. Hypotension is not a characteristic finding in Cushing's triad.
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 effectively pump blood to the lungs for oxygenation, causing blood to back up into the systemic circulation. This leads to fluid retention, particularly in the lower extremities and abdomen, resulting in increased abdominal girth. Crackles in the lungs (
A) are indicative of left-sided heart failure due to pulmonary congestion. Pink frothy sputum (
C) is associated with pulmonary edema, a sign of left-sided heart failure. Hypertension (
D) is not typically associated with right-sided heart failure, as it is more commonly seen in conditions like systemic hypertension.