ATI RN
ATI RN Adult Medical Surgical 2023 Questions Questions
Question 1 of 5
A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Request an interpreter during the initial assessment. This is the most appropriate action as it ensures effective communication between the nurse and the client who uses sign language. It upholds the client's right to clear and accurate information regarding their care. Asking a family member (choice
A) may not guarantee accurate communication and could breach confidentiality. Familiarizing oneself with sign language (choice
C) takes time and may not be sufficient for complex medical discussions. Using a board with pictures (choice
D) may not provide the client with the level of detail needed for comprehensive care. Overall, requesting an interpreter is the best choice for ensuring effective communication and respecting the client's rights.
Question 2 of 5
A nurse on an intensive care unit is planning care for a client who has increased intracranial pressure following a head injury. Which of the following IV medications should the nurse plan to administer?
Correct Answer: C
Rationale: The correct answer is C: Mannitol. Mannitol is an osmotic diuretic that helps reduce intracranial pressure by drawing fluid out of brain tissues. It is commonly used in the management of increased intracranial pressure in clients with head injuries. Propranolol (
A) is a beta-blocker used for hypertension and anxiety, not for reducing intracranial pressure. Dobutamine (
B) is a beta-1 agonist used for cardiac support, not for managing intracranial pressure. Chlorpromazine (
D) is an antipsychotic medication and is not indicated for reducing intracranial pressure.
Question 3 of 5
A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)?
Correct Answer: D
Rationale: The correct answer is D: Disequilibrium with movement. Cranial nerve VIII, the vestibulocochlear nerve, is responsible for both hearing and balance. Impaired function of this nerve can result in symptoms such as dizziness, vertigo, and disequilibrium with movement. This is because the vestibular branch of the nerve is crucial for maintaining balance and spatial orientation.
Choice A, loss of peripheral vision, is not related to cranial nerve VIII but rather to cranial nerve II, the optic nerve.
Choice B, inability to smell, is associated with cranial nerve I, the olfactory nerve.
Choice C, deviation of the tongue from midline, is a sign of dysfunction of cranial nerve XII, the hypoglossal nerve.
In summary, the correct answer is D because impaired function of the vestibulocochlear nerve (cranial nerve VIII) would result in disequilibrium with movement, while the other choices are related to different cranial
Question 4 of 5
A nurse is caring for a client who has left-sided heart failure. Which of the following findings should indicate to the nurse that the client is experiencing a decrease in cardiac output?
Correct Answer: D
Rationale: The correct answer is D: Dyspnea. In left-sided heart failure, the heart is unable to pump efficiently, leading to a decrease in cardiac output. Dyspnea (shortness of breath) occurs due to the accumulation of fluid in the lungs (pulmonary congestion), indicating decreased cardiac output. Weight gain (
A) and distended abdomen (
B) are more indicative of right-sided heart failure. Confusion (
C) can be a sign of decreased cerebral perfusion, but dyspnea is a more direct indicator of decreased cardiac output in left-sided heart failure.
Question 5 of 5
A nurse enters a client's room and observes the client having a tonic-clonic seizure. Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: The correct answer is C: Turn the client on their side. This is the first action the nurse should take during a seizure to prevent aspiration and maintain an open airway. Turning the client on their side helps to prevent choking and allows any fluids to drain out of the mouth. Obtaining vital signs (
A) and performing a neurologic check (
B) can be done after ensuring the client's safety. Notifying the rapid response team (
D) is important in some situations, but the immediate priority is to protect the client from harm during the seizure.