ATI RN
ATI RN Adult Medical Surgical 2023 V Questions
Extract:
Question 1 of 5
A nurse is assessing a client following the administration of an initial dose of captopril. Which of the following findings indicates an anaphylactic response?
Correct Answer: B
Rationale: Laryngeal edema is a hallmark of anaphylaxis, indicating airway swelling that requires immediate intervention. Fever, hypertension, and arrhythmia are not typical anaphylactic responses.
Question 2 of 5
A nurse is providing teaching to a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication?
Correct Answer: D
Rationale: Cloudy effluent is the earliest sign of peritonitis, indicating infection in the peritoneal cavity.
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: D
Rationale: Altered level of consciousness is the earliest sign of increased intracranial pressure, reflecting brain dysfunction.
Question 4 of 5
A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg, a fluid intake of 960 mL, and an output of 300 mL in the past 12 hr. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Dyspnea and fluid overload signs suggest slowing the infusion and notifying the provider to prevent worsening heart failure.
Extract:
History and Physical
1000:
Client reports after eating breakfast this morning at 0630 that they began feeling tightness in chest that radiates to left arm. History:
Hyperlipidemia, hypertension, type 2 diabetes mellitus. Non-smoker. Denies use of alcohol or recreational drug use.
Nurses' Notes
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.
Vital Signs
1000:
• Temperature 37.1° C (98.8° F)
• Heart rate 110/min and irregular
• Respiratory rate 24/min
• Blood pressure 164/80 mm Hg
• Oxygen saturation 93% on room air
Diagnostic Results
1000:
• Myoglobin 100 mcg/L (less than 90 mcg/L)
• Creatine kinase 180 units/L (55 to 170 units/L)
• Troponin T 0.40 ng/mL (less than 0.1 ng/mL)
• Troponin 10.35 ng/mL (less than 0.03 ng/mL)
• Cholesterol 244 mg/dL (less than 200 mg/dL)
• Triglycerides 180 mg/dL (40 to 160 mg/dL)
• LDL cholesterol 148 mg/dL (less than 130 mg/dL)
• HDL cholesterol 42 mg/dL (greater than 45 mg/dL)
• C-reactive protein 2 mg/mL (less than 1.0 mg/mL)
• Blood glucose 103 mg/dL (74 to 106 mg/dL)
12-lead electrocardiogram: tachycardia with ST segment elevation and T wave changes
Chest x-ray: lungs are clear in all lobes
Provider prescriptions
1020:
• Nitroglycerin 0.5 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 metoprolol 100 mg PO twice daily
• Initiate peripheral IV site
• 0.9% sodium chloride 50 mL/hr by continuous IV infusion
• Oxygen at 2 L/min via nasal cannula if oxygen saturation is less than 90%
• Schedule stat echocardiogram
• 2 g sodium diet
Question 5 of 5
The nurse is reviewing the client's medical record. Which of the following findings indicates the client's condition has improved? Select all that apply.
Correct Answer: A,B,C,D,E
Rationale: Decreased pain, normalized vital signs (respiratory rate, heart rate, blood pressure), and improved oxygenation indicate recovery.