ATI RN
ATI Med Surg Exam 9 Questions
Extract:
Question 1 of 5
A client receiving parenteral nutrition by central venous access reports feeling unwell. The nurse assesses the client and suspects that the central line has become infected. Which of the following findings indicate that the client has developed a systemic infection? Select all that apply.
Correct Answer: B,E,F
Rationale: Purulent drainage, leukocytosis, and fever indicate a systemic infection, as they reflect bacterial invasion and immune response spreading beyond the local site.
Question 2 of 5
A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.)
Correct Answer: B,E,F
Rationale: Bradycardia with bounding pulse, nonreactive dilated pupils, and hypotension with decreasing pulse pressure are late signs of ICP, associated with Cushing's triad and severe neurological compromise.
Question 3 of 5
A nurse is caring for a client who is postoperative from glaucoma surgery in the right eye. Which of the following will the nurse include in the postoperative education to the client? (Select all that apply)
Correct Answer: C,E,F
Rationale: These instructions ensure proper recovery by monitoring for complications, avoiding activities that increase intraocular pressure, and reassuring about normal post-surgical phenomena.
Question 4 of 5
A nurse is reviewing the medical record of a client who is experiencing delirium. Which of the following in the health record should the nurse identify as a cause of this disorder?
Correct Answer: C
Rationale: Seasonal allergies are not a cause of delirium, but a common condition that affects the respiratory system and causes symptoms such as sneezing, runny nose, itchy eyes, or coughing. History of GERD is not a cause of delirium, but a chronic condition that affects the digestive system and causes symptoms such as heartburn, regurgitation, chest pain, or difficulty swallowing. Benzodiazepines are a cause of delirium, especially in older adults or those with cognitive impairment. Benzodiazepines are a class of drugs that act on the central nervous system and cause sedation, relaxation, and reduced anxiety. However, they can also impair memory, attention, orientation, and judgment, and lead to confusion, agitation, hallucinations, or delusions. Completed antibiotics 10 days ago are not a cause of delirium, but a treatment for bacterial infections. Antibiotics can have side effects such as nausea, diarrhea, rash, or allergic reactions, but they do not cause delirium unless they are toxic or interact with other medications.
Question 5 of 5
A client's chart indicates that they are legally blind. Which of the following is the definition of legally blind?
Correct Answer: B
Rationale: Legal blindness is defined as a best-corrected visual acuity of 20/200 or worse in the better eye. Full vision loss in one eye, inability to see from 200 feet without lenses, or 20/60 impairment do not meet this criterion.