ATI RN
ATI RN Adult Medical Surgical 2023 III Questions
Extract:
Question 1 of 5
A nurse in the PACU is caring for a client. Which of the following assessments is the nurse's priority?
Correct Answer: B
Rationale: Respiratory status is the priority in the PACU to ensure airway patency and adequate oxygenation post-anesthesia.
Question 2 of 5
A nurse is planning care for a client who is postoperative following insertion of an arteriovenous graft in their left forearm. Which of the following actions should the nurse include in the plan of care?
Correct Answer: A
Rationale: Checking the distal pulse ensures adequate circulation and graft patency post-insertion.
Question 3 of 5
A nurse is assessing a client who has increased intracranial pressure. The nurse should recognize that which of the following is the first sign of deteriorating neurological status?
Correct Answer: A
Rationale: Altered level of consciousness is the earliest sign of neurological deterioration due to increased ICP.
Question 4 of 5
A nurse is caring for a client who has emphysema. Which of the following interventions should the nurse include in the client's plan of care?
Correct Answer: D
Rationale: Low-flow oxygen (e.g., 2 L/min) helps maintain adequate oxygenation in emphysema without suppressing the respiratory drive.
Extract:
History and Physical
Presenting Complaint:
Time of Onset: 0630 hours
Symptoms: Client reports tightness in chest that radiates to left arm after eating breakfast. The pain was initially rated as 7/10 and reduced to 5/10 after treatment with nitroglycerin. Client also experienced nausea, diaphoresis, and shortness of breath. Heart rate was irregular and tachycardic.
Medical History:
Conditions: Hyperlipidemia, hypertension, type 2 diabetes mellitus.
Lifestyle: Non-smoker. Denies use of alcohol or recreational drugs.
Nurses' Notes
1000 Hours:
Client reports tightness in chest that radiates to left arm. States pain as 7 on a scale of 0 to 10. Started to feel nauseous after breakfast. Client states, "I had scrambled eggs and bacon like I do every morning." Client is diaphoretic and short of breath. Heart rate irregular and tachycardic. Alert and oriented to person, place, and time. Lungs clear to auscultation in all lobes. Bowel sounds are present in all 4 quadrants. +1 pedal pulses. Skin is cool to touch. Capillary refill less than 2 seconds.
1200 Hours:
Client states chest pain is now a 5 on a scale of 0 to 10 after 2 doses of nitroglycerin. Breathing easier with oxygen applied at 2 L/min via nasal cannula.
Vital Signs
1000 Hours:
Temperature: 37.1°C (98.8°F)
Heart Rate: 110/min, irregular
Respiratory Rate: 24/min
Blood Pressure: 164/80 mm Hg
Oxygen Saturation: 93% on room air
1015 Hours:
Temperature: 36.7°C (98.2°F)
Heart Rate: 120/min, irregular
Respiratory Rate: 22/min
Blood Pressure: 176/82 mm Hg
Oxygen Saturation: 89% on room air
1200 Hours:
Temperature: 36.7°C (98.2°F)
Heart Rate: 100/min, irregular
Respiratory Rate: 22/min
Blood Pressure: 110/62 mm Hg
Oxygen Saturation: 92% on 2 L/min via nasal cannula
Intake/Output:
Intake: 500 mL
Output: 32 mL
Diagnostic Results
Myoglobin: 100 mcg/L (Normal: <90 mcg/L)
Creatine Kinase: 180 units/L (Normal: 55-170 units/L)
Troponin T: 0.40 ng/mL (Normal: <0.1 ng/mL)
Troponin I: 0.35 ng/mL (Normal: <0.03 ng/mL)
Cholesterol: 244 mg/dL (Normal: <200 mg/dL)
Triglycerides: 180 mg/dL (Normal: 40-160 mg/dL)
LDL Cholesterol: 148 mg/dL (Normal: <130 mg/dL)
HDL Cholesterol: 42 mg/dL (Normal: >45 mg/dL)
C-reactive Protein: 2 mg/mL (Normal: <1.0 mg/mL)
Blood Glucose: 103 mg/dL (Normal: 74-106 mg/dL)
12-Lead ECG: Tachycardia with ST segment elevation and T wave changes
Chest X-ray: Lungs clear in all lobes
Provider's Prescriptions
Nitroglycerin: 0.4 mg SL, may repeat every 5 min up to 3 doses as needed for chest pain
Aspirin: 160 mg PO daily
Morphine: 6 mg IV bolus every 3 hr PRN pain
Metoprolol: 25 mg PO every 6 hr x 48 hr, then 100 mg PO twice daily
Peripheral IV Site: Initiated
IV Fluids: 0.9% sodium chloride at 50 mL/hr continuous infusion
Oxygen: 2 L/min via nasal cannula if O2 saturation < 90%
Question 5 of 5
A nurse is reviewing the client's diagnostic results and vital signs. Which of the following actions should the nurse take?
Correct Answer: A,B,E
Rationale: Cardiac catheterization, heparin infusion, and NPO status are appropriate for managing acute coronary syndrome.