ATI RN
ATI RN Adult Medical Surgical 2023 V Questions
Question 1 of 5
A nurse is caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings should the nurse identify as an indication that the medication was effective?
Correct Answer: D
Rationale: Morphine reduces anxiety and preload in heart failure, improving comfort and breathing.
Question 2 of 5
A nurse is caring for a client immediately following a cardiac catheterization through the right femoral artery. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: Keeping the leg straight prevents bleeding or hematoma at the femoral puncture site, a critical post-catheterization precaution.
Question 3 of 5
A nurse is reviewing a client's ABG results and notes pH 7.3 (7.35 to 7.45), PaO2 81 mm Hg (80 to 100 mm Hg), PaCO2 50 mm Hg (35 to 45 mm Hg), and HCO3 26 mEq/L (21 to 28 mEq/L). Which of the following acid-base imbalances is the client experiencing?
Correct Answer: D
Rationale: Low pH (7.3) and high PaCO2 (50 mm Hg) indicate respiratory acidosis, likely due to CO2 retention.
Extract:
Nurses' Notes
0900:
Client came to the emergency department this morning and reports not feeling well for the last 12 hr and increasing blood glucose. Client has a history of type 1 diabetes mellitus and hypertension. Client weight is 88 kg (194 lb). The client was recently treated for bronchitis and pneumonia. Client reports nausea and decreased appetite.
Client is alert and orientated x 4, heart and lung sounds are clear. Client states that they have been frequently urinating and are extremely thirsty. Bowel sounds are hyperactive in all 4 quadrants. Bilateral pedal pulses 1+. Slight tenting of skin. Peripheral IV established and labs drawn.
Vital Signs
0900:
• Temperature 36.8° C (98.2° F)
• Pulse rate 110/min
• Respiratory rate 18/min
• Blood pressure 96/65 mm Hg
• Oxygen saturation 96% on room air
Laboratory Results
0915:
• Blood glucose 468 mg/dL (74 to 106 mg/dL)
• pH 7.30 (7.35 to 7.45)
• Potassium 5.5 mEq/L (3.5 to 5 mEq/L)
• Sodium 138 mEq/L (136 to 145 mEq/L)
• Chloride 101 mEq/L (98 to 106 mEq/L) BUN 21 mg/dL (10 to 20 mg/dL)
• Creatinine 1.7 mg/dL (0.5 to 1.1 mg/dL)
• Urine dipstick positive for ketones (negative)
Question 4 of 5
A nurse is caring for a client in the emergency department. The nurse understands that the client is at risk of developing which of the following complications? Select all that apply.
| Options | DKA | HHS |
|---|---|---|
| Hypotension | ||
| Respiratory alkalosis | ||
| Septic shock | ||
| Cardiac arrhythmias | ||
| Renal failure | ||
| Cerebral edema |
Correct Answer: A,D,E,F
Rationale: Hypotension, arrhythmias (from hyperkalemia), renal failure (from dehydration), and cerebral edema are DKA risks.
Extract:
Question 5 of 5
A nurse is assessing a client for a positive Chvostek's sign following a thyroidectomy. Which of the following areas on the client's head should the nurse tap to assess the client for tetany?
Correct Answer: B
Rationale: Tapping the facial nerve (cheek area) elicits a Chvostek's sign, indicating hypocalcemia post-thyroidectomy.