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 history of type 2 diabetes mellitus. The nurse should identify which of the following findings as an indication of a microvascular complication?
Correct Answer: C
Rationale: The correct answer is C: Retinopathy. In type 2 diabetes mellitus, microvascular complications involve damage to small blood vessels. Retinopathy specifically affects the blood vessels in the retina, leading to vision problems. Peripheral neuropathy (
A) is a macrovascular complication affecting nerves. Hypertension (
B) is a common comorbidity in diabetes but not a direct microvascular complication. Stroke (
D) is a macrovascular complication involving larger blood vessels in the brain.
Therefore, the presence of retinopathy is a clear indication of a microvascular complication in a client with type 2 diabetes mellitus.
Question 2 of 5
A nurse is assessing a client who has a chest tube connected to a closed water-seal drainage system. Which of the following findings should the nurse report to the provider?
Correct Answer: A
Rationale: The correct answer is A: Constant bubbling in the water seal chamber. This finding indicates an air leak in the system, which can compromise the client's respiratory status. The continuous bubbling signifies that air is escaping through the chest tube rather than being properly drained. The nurse should report this to the provider immediately for further evaluation and intervention to prevent pneumothorax or other complications.
The other choices (B, C,
D) are incorrect because intermittent bubbling in the suction chamber is expected as it indicates proper functioning of the system. Clear drainage of 50 mL over 8 hours is within normal limits and does not pose an immediate threat to the client. Mild pain at the insertion site is also a common finding after chest tube insertion and does not require urgent intervention unless it worsens or is accompanied by other concerning symptoms.
Question 3 of 5
A nurse is assessing a client who has a history of type 2 diabetes mellitus. The nurse should identify which of the following findings as an indication of a microvascular complication?
Correct Answer: C
Rationale: The correct answer is C: Retinopathy. In type 2 diabetes mellitus, microvascular complications involve damage to small blood vessels. Retinopathy specifically affects the blood vessels in the retina, leading to vision problems. Peripheral neuropathy (
A) is a macrovascular complication affecting nerves. Hypertension (
B) is a common comorbidity in diabetes but not a direct microvascular complication. Stroke (
D) is a macrovascular complication involving larger blood vessels in the brain.
Therefore, the presence of retinopathy is a clear indication of a microvascular complication in a client with type 2 diabetes mellitus.
Question 4 of 5
A nurse is preparing to administer potassium chloride 10 mEq IV over 1 hr to a client. Available is potassium chloride 10 mEq in 100 mL of 0.9% sodium chloride. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number.)
Correct Answer: C
Rationale:
To calculate the infusion rate, we need to use the formula: (Desired dose ÷ Volume) x 60 minutes. In this case, the desired dose is 10 mEq over 1 hour, and the volume is 100 mL.
So, (10 ÷ 100) x 60 = 6 mL/hr.
Therefore, the nurse should set the infusion pump to deliver 100 mL/hr. This ensures the correct administration of potassium chloride over the specified time frame.
Choice A (50 mL/hr) and B (75 mL/hr) are incorrect as they would result in the underdosing of potassium chloride.
Choice D (125 mL/hr) is incorrect as it would result in the overdosing of potassium chloride. The correct answer, C (100 mL/hr), ensures the proper administration of the medication within the specified parameters.
Question 5 of 5
A nurse is planning care for a client who had a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care?
Correct Answer: B
Rationale: The correct answer is B: Turn the client by log rolling with a turning sheet. This is the correct intervention because after a lumbar laminectomy, it is crucial to protect the surgical site and avoid bending or twisting the spine. Log rolling with a turning sheet helps maintain proper alignment and prevent injury to the surgical area.
Choice A is incorrect because encouraging the client to ambulate independently may put stress on the surgical area.
Choice C is incorrect as positioning the client in a high Fowler's position may also strain the spine.
Choice D is incorrect because applying a heating pad to the lower back can increase the risk of burns and should be avoided near a surgical site.