ATI RN
RN ATI Adult Medsurg Proctored Exam 2023 With NGN Questions
Extract:
Question 1 of 5
A nurse is assessing a client who has a central venous catheter (CVC) with intravenous (IV) fluids infusing. The client suddenly develops shortness of breath, and the nurse notes that the IV tubing and needleless connector device are disconnected. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Close the pinch clamp on the CVC. This action is crucial to prevent air embolism, a potentially life-threatening complication of central venous catheter disconnection. Closing the pinch clamp will stop air from entering the bloodstream and minimize the risk of air embolism. Administering oxygen (
B) is important, but closing the pinch clamp takes priority to prevent immediate harm. Placing the client in Trendelenburg position (
C) is not recommended as it can worsen air embolism by allowing air to travel to the heart. Obtaining emergency IV access (
D) is not the first priority in this situation; preventing air embolism is critical.
Question 2 of 5
A home health nurse is inspecting a clients residence for electrical hazards as part of the agencys quality improvement plan. Which of the following findings should the nurse identify as a safety hazard?
Correct Answer: A
Rationale:
Correct Answer: A. An IV pump is plugged into an outlet near a sink.
Rationale: Plugging an IV pump near a sink poses a significant risk of electrical shock due to water exposure. Water conducts electricity and can lead to electrocution. This situation directly violates electrical safety guidelines.
Summary of other choices:
B. A lamp with a short cord in the bedroom: While a short cord may not be ideal, it does not pose an immediate safety hazard unless it is frayed or damaged.
C. A television plugged into a surge protector: This is a safe practice as surge protectors help prevent damage from power surges and do not pose a direct safety hazard.
D. The client uses a nightlight in the hallway: Nightlights are commonly used for safety and do not typically pose an electrical hazard if used correctly.
Question 3 of 5
A nurse is monitoring a client following a lumbar laminectomy. The client has a drain and indwelling urinary catheter. The nurse should identify which of the following findings as an indication of a complication of the surgery?
Correct Answer: C
Rationale: The correct answer is C: Clear drainage on the dressings. Clear drainage may indicate a cerebrospinal fluid leak, which is a serious complication following a lumbar laminectomy. Cerebrospinal fluid is a clear fluid that surrounds the brain and spinal cord, and its leakage can lead to infection and other complications. Red-tinged drainage (choice
A) may be expected initially due to surgical trauma. Cloudy urine in the catheter (choice
B) is more likely related to urinary tract infection. Mild back pain at the surgical site (choice
D) is common after this surgery and does not necessarily indicate a complication.
Question 4 of 5
A nurse is caring for a client immediately following intubation with an endotracheal (ET) tube. Which of the following methods should the nurse identify as the most reliable for verifying placement of the ET tube?
Correct Answer: C
Rationale: The correct answer is C: Using an end-tidal CO2 detector. This method is the most reliable for verifying ET tube placement because it directly measures the presence of CO2 in exhaled breath, confirming that the tube is in the trachea. This is crucial to prevent inadvertent esophageal intubation. Observing for symmetrical chest rise and fall (
A) can be misleading as it can occur even with esophageal intubation. Auscultating bilateral breath sounds (
B) can also be unreliable as breath sounds may be heard even if the tube is in the esophagus. Checking for condensation in the ET tube (
D) is not a reliable method for verifying placement as condensation can occur regardless of tube placement.
Question 5 of 5
A nurse is assessing a client who has a central venous catheter (CVC) with intravenous (IV) fluids infusing. The client suddenly develops shortness of breath, and the nurse notes that the IV tubing and needleless connector device are disconnected. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Close the pinch clamp on the CVC. This action is crucial to prevent air embolism, a potentially life-threatening complication of central venous catheter disconnection. Closing the pinch clamp will stop air from entering the bloodstream and minimize the risk of air embolism. Administering oxygen (
B) is important, but closing the pinch clamp takes priority to prevent immediate harm. Placing the client in Trendelenburg position (
C) is not recommended as it can worsen air embolism by allowing air to travel to the heart. Obtaining emergency IV access (
D) is not the first priority in this situation; preventing air embolism is critical.