ATI RN
ATI Med Surg Nurs 300 Day Exam 4 Questions
Question 1 of 5
The nurse is admitting a client who is on a ventilator. The client has a medical diagnosis of acute respiratory distress syndrome (ARDS). Which infection control guideline is of greatest importance?
Correct Answer: A
Rationale: Hand hygiene is the most critical infection control measure to prevent ventilator-associated infections in ARDS patients.
Question 2 of 5
The nurse is to begin a nitroglycerin infusion for a client diagnosed with an anterior wall myocardial infarction. Which assessment finding should the nurse report to the provider immediately?
Correct Answer: D
Rationale: A blood pressure of 90/50 mmHg is significantly low and could indicate hypotension, a known side effect of nitroglycerin infusion. This can compromise perfusion to vital organs and may require adjustment or discontinuation of the infusion, making it the most urgent finding to report.
Question 3 of 5
The nurse administers IV nitroglycerin to a client diagnosed with an acute myocardial infarction. In evaluating the effectiveness of this intervention, the nurse should monitor for:
Correct Answer: B
Rationale: The primary therapeutic goal of nitroglycerin in acute myocardial infarction is to relieve chest pain by dilating blood vessels, reducing myocardial oxygen demand, and improving blood flow to the heart.
Question 4 of 5
The nurse is caring for the client experiencing Guillain-Barre syndrome (GBS). It is most important for the nurse to monitor the client for which complication?
Correct Answer: C
Rationale: Respiratory failure is the most life-threatening complication in GBS due to paralysis affecting breathing muscles.
Question 5 of 5
When caring for a client with a chest tube, the nurse would avoid the practice
Correct Answer: B
Rationale: Stripping the chest tube can increase intrathoracic pressure, risking tension pneumothorax, and is an outdated practice.