ATI RN
ATI RN Adult Medical Surgical 2023 III Questions
Extract:
Question 1 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: A
Rationale: Altered level of consciousness is the earliest sign of neurological deterioration due to increased ICP.
Question 2 of 5
A nurse is caring for a client who has been prescribed an antibiotic. The client tells the nurse, 'I don't like taking medications because I don't think I need them.' Which of the following responses should the nurse make?
Correct Answer: D
Rationale: Informing the provider respects the client's autonomy and ensures the care plan is adjusted accordingly.
Extract:
History and Physical
Presenting Complaint:
Time of Onset: 0630 hours
Symptoms: Client reports tightness in chest that radiates to left arm after eating breakfast. The pain was initially rated as 7/10 and reduced to 5/10 after treatment with nitroglycerin. Client also experienced nausea, diaphoresis, and shortness of breath. Heart rate was irregular and tachycardic.
Medical History:
Conditions: Hyperlipidemia, hypertension, type 2 diabetes mellitus.
Lifestyle: Non-smoker. Denies use of alcohol or recreational drugs.
Nurses' Notes
1000 Hours:
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.
1200 Hours:
Client states chest pain is now a 5 on a scale of 0 to 10 after 2 doses of nitroglycerin. Breathing easier with oxygen applied at 2 L/min via nasal cannula.
Vital Signs
1000 Hours:
Temperature: 37.1°C (98.8°F)
Heart Rate: 110/min, irregular
Respiratory Rate: 24/min
Blood Pressure: 164/80 mm Hg
Oxygen Saturation: 93% on room air
1015 Hours:
Temperature: 36.7°C (98.2°F)
Heart Rate: 120/min, irregular
Respiratory Rate: 22/min
Blood Pressure: 176/82 mm Hg
Oxygen Saturation: 89% on room air
1200 Hours:
Temperature: 36.7°C (98.2°F)
Heart Rate: 100/min, irregular
Respiratory Rate: 22/min
Blood Pressure: 110/62 mm Hg
Oxygen Saturation: 92% on 2 L/min via nasal cannula
Intake/Output:
Intake: 500 mL
Output: 32 mL
Diagnostic Results
Myoglobin: 100 mcg/L (Normal: <90 mcg/L)
Creatine Kinase: 180 units/L (Normal: 55-170 units/L)
Troponin T: 0.40 ng/mL (Normal: <0.1 ng/mL)
Troponin I: 0.35 ng/mL (Normal: <0.03 ng/mL)
Cholesterol: 244 mg/dL (Normal: <200 mg/dL)
Triglycerides: 180 mg/dL (Normal: 40-160 mg/dL)
LDL Cholesterol: 148 mg/dL (Normal: <130 mg/dL)
HDL Cholesterol: 42 mg/dL (Normal: >45 mg/dL)
C-reactive Protein: 2 mg/mL (Normal: <1.0 mg/mL)
Blood Glucose: 103 mg/dL (Normal: 74-106 mg/dL)
12-Lead ECG: Tachycardia with ST segment elevation and T wave changes
Chest X-ray: Lungs clear in all lobes
Provider's Prescriptions
Nitroglycerin: 0.4 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 100 mg PO twice daily
Peripheral IV Site: Initiated
IV Fluids: 0.9% sodium chloride at 50 mL/hr continuous infusion
Oxygen: 2 L/min via nasal cannula if O2 saturation < 90%
Question 3 of 5
For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.
| Options | Anticipated | Nonessential | Contraindicated |
|---|---|---|---|
| Metoprolol 5 mg every 2 to 3 min up to three doses | |||
| Oxygen at 2 L/min via nasal cannula | |||
| Draw electrolytes along with Hgb and Hct | |||
| Morphine 6 mg IV bolus every 3 hr as needed for pain | |||
| Nitroglycerin 0.4 mg SL now may repeat every 5 min up to 3 doses | |||
| Obtain daily weight | |||
| Atropine 0.5 mg IV bolus every 5 min up to 2 mg |
Correct Answer: (See rationale)
Rationale: Oxygen, morphine, nitroglycerin, and electrolytes are anticipated; metoprolol dosing is incorrect; atropine is contraindicated; daily weight is nonessential.
Extract:
Question 4 of 5
A nurse is assessing a client who has heart failure and a new prescription for metoprolol. Which of the following findings should the nurse identify as an adverse effect of the medication?
Correct Answer: A
Rationale: Metoprolol, a beta-blocker, can cause bradycardia (heart rate <60/min) as an adverse effect.
Question 5 of 5
A nurse is teaching a client who has left-sided weakness how to use a quad cane. Which of the following client actions indicates an understanding of the teaching?
Correct Answer: A
Rationale: Advancing the weaker leg to the cane provides stability and support during ambulation.