ATI RN
ATI RN Adult Medical Surgical 2023 Questions Correct Answers Questions
Extract:
Question 1 of 5
A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse identify as a manifestation of right-sided heart failure?
Correct Answer: B
Rationale: The correct answer is B: Increased abdominal girth. In right-sided heart failure, the heart is unable to effectively pump blood to the lungs for oxygenation, causing blood to back up into the systemic circulation. This leads to fluid retention, particularly in the lower extremities and abdomen, resulting in increased abdominal girth. Crackles in the lungs (
A) are indicative of left-sided heart failure due to pulmonary congestion. Pink frothy sputum (
C) is associated with pulmonary edema, a sign of left-sided heart failure. Hypertension (
D) is not typically associated with right-sided heart failure, as it is more commonly seen in conditions like systemic hypertension.
Question 2 of 5
A nurse is caring for a client who has tuberculosis. Which of the following precautions should the nurse implement for this client?
Correct Answer: B
Rationale: The correct answer is B: Airborne precautions. Tuberculosis is spread through airborne transmission, so implementing airborne precautions is essential to prevent the spread of the disease. This includes wearing an N95 mask, placing the client in a negative pressure room, and ensuring proper ventilation. Standard precautions (choice
A) are used for all clients, not specifically for tuberculosis. Contact precautions (choice
C) are used for diseases spread by direct contact, while droplet precautions (choice
D) are used for diseases spread through respiratory droplets, not airborne transmission like tuberculosis.
Question 3 of 5
A nurse is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement?
Correct Answer: C
Rationale: The correct answer is C: Use a bed alarm. This is the most appropriate action to help prevent the client from wandering and ensure their safety. A bed alarm will alert the nurse when the client tries to get out of bed, allowing for timely intervention. Moving the client to a double room (
A) may not necessarily prevent wandering. Using chemical restraints (
B) is not recommended due to ethical concerns and potential adverse effects. Encouraging excessive stimulation (
D) may increase agitation and wandering behavior.
Question 4 of 5
A nurse is assessing a client who is 24 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Maintain abduction of the affected extremity. After a total hip arthroplasty, maintaining abduction of the affected extremity helps prevent dislocation of the hip prosthesis. This position helps stabilize the hip joint and reduces the risk of complications. Option B (Position the client in high Fowler's position) is incorrect as it does not directly address the postoperative care specific to a total hip arthroplasty. Option C (Encourage the client to cross their legs at the ankles) is incorrect because crossing legs can create pressure on the hip joint and increase the risk of dislocation. Option D (Have the client bend forward at the waist while sitting) is incorrect as this could also increase the risk of hip dislocation.
Question 5 of 5
A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse identify as a manifestation of right-sided heart failure?
Correct Answer: B
Rationale: The correct answer is B: Increased abdominal girth. In right-sided heart failure, the heart is unable to effectively pump blood to the lungs for oxygenation, causing blood to back up into the systemic circulation. This leads to fluid retention, particularly in the lower extremities and abdomen, resulting in increased abdominal girth. Crackles in the lungs (
A) are indicative of left-sided heart failure due to pulmonary congestion. Pink frothy sputum (
C) is associated with pulmonary edema, a sign of left-sided heart failure. Hypertension (
D) is not typically associated with right-sided heart failure, as it is more commonly seen in conditions like systemic hypertension.