ATI RN
ATI Advanced Med Surg Exam 3 Questions
Extract:
Question 1 of 5
A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: Elevated CVP reflects systemic venous congestion, a hallmark of right-sided heart failure.
Extract:
Four hours after her arrival to the emergency department, the patient remains in second-degree type II heart block and her vital signs are stable. She is transferred to a telemetry unit to prepare for insertion of a permanent pacemaker later in the day. When she gets out of bed to use the restroom, she felt faint and had to sit on the floor. The nurse finds her sitting on the floor beside the commode; the patient is awake but somewhat confused. The nurse notes that the ECG monitor shows that the patient's heart rate is at 40 beats/minute and she is now in third degree heart block. The Rapid Response team is called, and preparations are made for the immediate application of a transcutaneous pacemaker (TCP).
Question 2 of 5
Which nursing actions should be included in the plan of care for the patient (Select All that Apply.)
Correct Answer: B,C,D,E,F
Rationale: Monitoring vital signs and ECG ensures stability, reassurance reduces anxiety, atropine may be used for bradycardia, proper pad placement ensures effective pacing, and analgesia addresses discomfort.
Extract:
Question 3 of 5
A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Administering oxygen addresses hypoxemia and supports respiratory effort in a client with a sucking chest wound.
Question 4 of 5
A patient with respiratory failure has a respiratory rate of 26 breaths/min and an oxygen saturation (SpO2) of 80%. The patient is increasingly pale and restless but follows commands. Which intervention will the nurse anticipate?
Correct Answer: B
Rationale: Severe hypoxemia and respiratory distress require endotracheal intubation for adequate ventilation and oxygenation.
Question 5 of 5
A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?
Correct Answer: D
Rationale: A pulse deficit between apical and radial pulses indicates irregular ventricular contractions typical of atrial fibrillation.