ATI RN
ATI n269 Med Surg Exam Questions
Question 1 of 5
After observing blood-tinged mucous when suctioning a patient who has just arrived on the medical-surgical unit after a laryngectomy, which action by the nurse is best?
Correct Answer: A
Rationale: Placing the patient in a lateral recovery position is the best immediate action. This position helps facilitate drainage of secretions, especially after a laryngectomy, which can reduce the risk of aspiration and airway obstruction. The blood-tinged mucus may be due to recent surgery and should be monitored for changes.
Question 2 of 5
The nurse notes that which disorder places the patient at greatest risk for hypertensive crisis?
Correct Answer: A
Rationale: Pheochromocytoma is a tumor of the adrenal glands that can cause excessive production of catecholamines (such as norepinephrine and epinephrine), leading to a hypertensive crisis. This condition can cause severe hypertension, headaches, palpitations, and sweating.
Question 3 of 5
Which condition may be observed due to incorrect fluid replacement with hypotonic fluids in patients with diabetic ketoacidosis?
Correct Answer: A
Rationale: Cerebral edema is the most dangerous complication associated with the administration of hypotonic fluids in patients with diabetic ketoacidosis (DK
A). This occurs because hypotonic fluids cause rapid shifts in fluid and electrolytes, which can lead to swelling of the brain, especially in children. The risk is heightened if fluids are replaced too quickly.
Question 4 of 5
Which of the following assessment findings indicates an emergency and the need for immediate action on the part of the nurse?
Correct Answer: B
Rationale: Tracheal deviation is a medical emergency and typically indicates tension pneumothorax, where air accumulates in the pleural space, shifting the trachea away from the affected side. This can compress the heart and lungs, leading to respiratory and circulatory collapse, requiring immediate action.
Question 5 of 5
In reviewing admission orders for a patient admitted with SIADH, the nurse should question which order?
Correct Answer: A
Rationale: In SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion), the body retains excessive water, leading to dilutional hyponatremia (low sodium levels). Administering hypertonic saline (3% NS) can exacerbate the condition by rapidly increasing sodium levels, which may cause demyelination of neurons (a condition called osmotic demyelination syndrome). Hypertonic saline is typically only used in severe hyponatremia with neurologic symptoms and should be carefully monitored.