ATI RN Adult Med-Surg 2023

Extract:

Nurses' Notes
Vital Signs
Diagnostic Results
1000:

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.

Question 1 of 5

A nurse is admitting a client who reports tightness in their chest that radiates to left arm. The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up.

A. Blood glucose level B. Bowel sounds C. Blood pressure D. Pain level E. Electrocardiogram findings F. Lung sounds G. Troponin T level

Correct Answer: C,D,E,G

Rationale: Chest pain with radiation suggests a cardiac event; BP, pain, ECG, and troponin are critical.

Extract:

Question 2 of 5

A nurse is assessing the pain status of a group of clients. Which of the following findings indicates a client is experiencing referred pain?

A. A client who has peritonitis reports generalized abdominal pain. B. A client who has pancreatitis reports pain in the left shoulder. C. A client who has angina reports substernal chest pain. D. A client who is postoperative reports incisional pain.

Correct Answer: B

Rationale: Referred pain from pancreatitis often radiates to the left shoulder.

Question 3 of 5

A nurse is caring for a client who is 3 hr postoperative following a total knee arthroplasty. Which of the following actions should the nurse take to prevent venous thromboembolism?

A. Keep the client's knees in a flexed position while they are in bed. B. Massage the client's legs every 4 hr while they are awake. C. Encourage the client to perform circumduction of the feet. D. Limit the client's fluid intake to 2,000 mL daily.

Correct Answer: C

Rationale: Foot circumduction promotes venous return, reducing thromboembolism risk.

Question 4 of 5

A nurse is caring for a client who has a herniated disc and is scheduled for a peripheral nerve block. The client tells the nurse, 'I am afraid to have this procedure.' Which of the following responses should the nurse make?

A. After this procedure, you will feel much better. B. Let's discuss your concerns about this procedure. C. Are you afraid of needles that will be used during the procedure? D. Tell me why you are scared to have this procedure.

Correct Answer: B

Rationale: Discussing concerns validates the client's feelings and encourages communication.

Question 5 of 5

A nurse on the medical-surgical unit is caring for a client who has a seizure disorder. Which of the following interventions should the nurse include in the plan of care?

A. Pad the upper two side rails of the client's bed. B. Maintain peripheral IV access. C. Teach assistive personnel how to apply restraints. D. Keep a padded tongue blade at the client's bedside.

Correct Answer: A

Rationale: Padding side rails prevents injury during seizures; tongue blades are not recommended.

ATI RN Adult Med-Surg 2023 | Nurselytic

Nurselytic

ATI RN

ATI RN