ATI RN
ATI Med Surg Final Exam Nsg 232 Questions
Extract:
Question 1 of 5
A home health nurse is making a home visit to a client who takes a daily diuretic for heart failure. Which of the following findings should the nurse report to the provider?
Correct Answer: D
Rationale: Rapid weight gain of 3 pounds in 24 hours suggests fluid overload, requiring urgent reporting.
Question 2 of 5
A nurse is caring for a client diagnosed with infective endocarditis. Which of the following manifestations indicate that the client's condition is worsening?
Correct Answer: A
Rationale: Worsening dyspnea may indicate complications like heart failure or pulmonary embolism, suggesting a deteriorating condition.
Extract:
Nurses' Notes
1500:
Client presents to the ED and reports dyspnea, chest pain, and tachycardia. Client returned home from a vacation out of the country 24 hr ago.
1515:
The client has become diaphoretic, increasingly dyspneic, and states that their chest pain is sharp and increasing. The client states. "I feel like I'm going to die." Crackles auscultated in bilateral lower lobes, s3 and S4 heart sounds noted. Petechiae noted on the client's chest. Pulmonary embolism protocol initiated.
Vital signs
1500
T 38.1 (100.6 F),
HR 110/min, RR 24/min.
BP 138/52 (02)92% at 2L nasal canula 1515:
T 100.6 F,
HR 135/min, RR 32/min,
BP 120/50 mmHg,
02 90% at 4L nasal canula
Question 3 of 5
A nurse is caring for a client in the emergency department (ED). The nurse should first followed by
Correct Answer: A, E
Rationale: High Fowler's position improves breathing, and IV access prepares for medication administration in suspected pulmonary embolism.
Extract:
Question 4 of 5
A nurse is caring for a client on a mechanical ventilator receiving a neuromuscular blockade agent. The nurse should prioritize which action?
Correct Answer: B
Rationale: Reporting the absence of spontaneous respirations is critical as it may indicate inadequate ventilation requiring immediate intervention.
Question 5 of 5
A nurse is caring for a client diagnosed with pulmonary embolism. Which new-onset assessment finding should a nurse expect in a client diagnosed with a pulmonary embolism?
Correct Answer: A
Rationale: Tachypnea is a common symptom of pulmonary embolism due to impaired oxygenation.