ATI RN
ATI Med Surg 2 Questions
Extract:
Question 1 of 5
A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. Which of the following complications should the nurse monitor the client for?
Correct Answer: A,C,D,F
Rationale: Correct choices include weakened gag reflex, absence of bowel sounds, paralysis, and hypotension, which are complications of cervical spinal cord injury.
Question 2 of 5
A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse that the client is developing this condition?
Correct Answer: D
Rationale: Breathlessness is a manifestation of left-sided heart failure, caused by pulmonary congestion and edema impairing gas exchange.
Question 3 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 4 of 5
A nurse is assisting with obtaining an electrocardiogram (ECG) for a client who has atrial fibrillation. Which of the following actions should the nurse take?
Correct Answer: A,B
Rationale: Inspecting electrode pads and instructing the client not to talk ensure accurate ECG results.
Question 5 of 5
A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level?
Correct Answer: C
Rationale: A self-report pain rating scale is the most valid method to assess pain, even with expressive aphasia, using simple scales.