ATI RN
ATI RN Adult Medical Surgical 2023 Questions
Extract:
Physical Examination
Jaundice
Orange-brown colored urine
Positive hemoccult blood
Abdominal distention
Lethargy
1+ edema
Oriented x4
Tachydysrhythmia
Dyspnea with exertion
A nurse is admitting a middle adult client who has cirrhosis. Findings upon admission:
Question 1 of 5
A nurse is admitting a middle adult client who has cirrhosis. Findings upon admission: The nurse is assessing the client 24 hr later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition.
| Options | Unrelated to diagnosis | Indication of Potential Improvement | Indication of Potential Worsening Condition |
|---|---|---|---|
| Spontaneous bruising | |||
| Ascites | |||
| Increased albumin level | |||
| Hematemesis | |||
| Elevated iron levels |
Correct Answer:
Rationale: Spontaneous bruising and hematemesis worsen cirrhosis; ascites is related; increased albumin improves; iron is unrelated.
Extract:
Question 2 of 5
A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia. Which of the following assessment findings requires immediate intervention by the nurse?
Correct Answer: D
Rationale: A capillary refill of 6 seconds indicates impaired circulation requiring immediate intervention.
Question 3 of 5
A nurse is planning care for a client who has developed nephrotic syndrome. Which of the following dietary recommendations should the nurse include?
Correct Answer: B
Rationale: Decreasing protein intake reduces proteinuria in nephrotic syndrome.
Question 4 of 5
A nurse in an emergency department is caring for a client who is receiving treatment for excessive ingestion of antacids. The nurse should identify that this client is at risk for which of the following acid-base imbalances?
Correct Answer: C
Rationale: Excessive antacid ingestion can lead to metabolic alkalosis due to increased base intake.
Question 5 of 5
A nurse is planning care for a client who has hemiplegia. Which of the following interventions should the nurse include?
Correct Answer: C
Rationale: Pillows between the knees prevent adduction and pressure ulcers in hemiplegia.