ATI RN
ATI RN Adult Medical Surgical 2023 Questions Questions
Extract:
Question 1 of 5
A nurse is assessing a client who has a urinary catheter. The nurse notes the client's IV tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse should identify that the client is at risk for which of the following conditions?
Correct Answer: B
Rationale: The correct answer is B: Infection. When IV tubing is kinked, it can lead to a backflow of urine from the catheter into the tubing, increasing the risk of contamination and subsequent urinary tract infection. Additionally, when the urinary catheter bag is lying next to the client in bed, there is a higher chance of accidental contamination. Infections can lead to serious complications and require prompt intervention. Neurogenic bladder (
A) is related to nerve damage affecting bladder control, not directly related to the current situation. Skin breakdown (
C) may occur due to prolonged contact with urine but is not the immediate concern here. Phlebitis (
D) is inflammation of a vein, not directly linked to the urinary catheter issue.
Question 2 of 5
A nurse is caring for a client who has a full chest, which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Provide humidified oxygen. This is because the client with a full chest may be experiencing difficulty breathing, and humidified oxygen can help improve oxygenation and relieve respiratory distress. Inpatient fluid reduction (choice
A) is not indicated without further assessment. Admonitor antibiotic medication (choice
C) is not directly related to addressing the client's respiratory distress. Administering acute/micoplasm (café) (choice
D) is not a recognized medical intervention. Providing humidified oxygen is the most appropriate initial action to address the client's respiratory symptoms.
Question 3 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: A
Rationale: The correct answer is A because a capillary refill of 6 seconds in the left toe indicates poor circulation, which could lead to ischemia or necrosis in the extremity. Immediate intervention is necessary to prevent further complications.
Choice B is not as urgent as it involves monitoring and managing drainage, which can be addressed after the circulation concern is addressed.
Choice C, an elevated temperature, may indicate infection but is not as immediately life-threatening as poor circulation.
Choice D, pain at the operative site, is important but does not require immediate intervention as it can be managed with pain medication.
Question 4 of 5
A nurse is caring for a client who has left-sided heart failure. Which of the following findings should indicate to the nurse that the client is experiencing a decrease in cardiac output?
Correct Answer: D
Rationale: The correct answer is D: Dyspnea. In left-sided heart failure, the heart is unable to pump efficiently, leading to a decrease in cardiac output. Dyspnea (shortness of breath) occurs due to the accumulation of fluid in the lungs (pulmonary congestion), indicating decreased cardiac output. Weight gain (
A) and distended abdomen (
B) are more indicative of right-sided heart failure. Confusion (
C) can be a sign of decreased cerebral perfusion, but dyspnea is a more direct indicator of decreased cardiac output in left-sided heart failure.
Question 5 of 5
A nurse is planning care for an older adult client who has a history of dementia and is admitted following surgical repair of a hip fracture. Which of the following actions should the nurse plan to take?
Correct Answer: C
Rationale: The correct answer is C: Play serene soothing music. Music therapy has been shown to be effective in reducing anxiety and agitation in individuals with dementia. Serene music can help create a calming environment, promoting relaxation and potentially improving the client's overall well-being. Encouraging visits from friends (
Choice
A) may overwhelm the client with dementia. Applying restraints to the upper extremities (
Choice
B) is not recommended as it can lead to physical and psychological harm. Keeping the over-the-bed light on (
Choice
D) may disrupt the client's sleep and exacerbate confusion.