ATI RN
ATI Med Surg 2 Questions
Extract:
Question 1 of 5
A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?
Correct Answer: C
Rationale: Atrial fibrillation causes irregular palpitations, fatigue, dizziness, and pulse deficit due to ineffective atrial contractions.
Question 2 of 5
A nurse is caring for a client who was admitted with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Providing frequent oral and nares care prevents infection and irritation from the tube.
Question 3 of 5
A nurse in the emergency department is caring for a client who sustained a head injury. The nurse notes the client's IV fluids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse?
Correct Answer: C
Rationale: Continuing at 125 mL/hr maintains hydration without risking fluid overload or increased intracranial pressure.
Question 4 of 5
A nurse is caring for a client who has a serum potassium level of 5.5 mEq/L. The provider prescribes polystyrene sulfonate. If this medication is effective, the nurse should expect which of the following changes on the client's ECG?
Correct Answer: C
Rationale: This is correct because a reduction of T-wave amplitude is a sign of hyperkalemia reversal. Polystyrene sulfonate lowers serum potassium, reversing ECG changes like peaked T waves.
Question 5 of 5
A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?
Correct Answer: B
Rationale: This is correct because increased respiratory rate is an early sign of shock, indicating hypoxia as a compensatory mechanism.