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 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 efficiently pump blood to the lungs for oxygenation, leading to fluid backup in the systemic circulation. This results in fluid retention, particularly in the abdomen, causing increased abdominal girth. Crackles in the lungs (choice
A) are indicative of left-sided heart failure. Pink frothy sputum (choice
C) is a sign of pulmonary edema, which is a manifestation of left-sided heart failure. Hypertension (choice
D) is not typically associated with right-sided heart failure.
Question 2 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.
Question 3 of 5
An emergency room nurse is assessing a client who has asthma and difficulty breathing. Which of the following findings should indicate to the nurse that the client is experiencing status asthmaticus?
Correct Answer: B
Rationale: The correct answer is B: Use of accessory muscles. In status asthmaticus, a severe and life-threatening asthma exacerbation, the client's airways are severely constricted, leading to inadequate air exchange. The use of accessory muscles (such as intercostal and supraclavicular muscles) indicates significant respiratory distress as the body tries to compensate for the difficulty in breathing. Mild wheezing (choice
A) may be present in asthma but does not necessarily indicate status asthmaticus. Decreased respiratory rate (choice
C) is not consistent with the increased respiratory effort seen in status asthmaticus. Productive cough (choice
D) is more indicative of conditions such as bronchitis or pneumonia, not necessarily status asthmaticus.
Question 4 of 5
A nurse is caring for a client who had a surgical repair of an abdominal aortic aneurysm 3 days ago. The clients vital signs are: temperature 38.3° C (100.9° F), heart rate 80/min, respirations 16/min, and blood pressure 128/76 mm Hg. Which of the following actions is the nurses priority?
Correct Answer: C
Rationale: The correct answer is C: Assess the surgical incision for signs of infection. This is the priority because the client has a fever (indicating possible infection) post-surgery, putting them at risk for complications. Assessing the surgical incision allows for early detection of infection, prompt treatment, and prevention of further complications. Administering an antipyretic (choice
A) only addresses the symptom but not the underlying cause. Encouraging ambulation (choice
B) and increasing IV fluids (choice
D) are important but assessing for infection takes precedence due to the potential severity of an infected surgical site.
Question 5 of 5
A nurse is caring for a client who is intubated and receiving mechanical ventilation for heroin toxicity. Which of the following assessments is the nurses priority?
Correct Answer: C
Rationale: The correct answer is C: Check ABGs. In this scenario, monitoring the client's arterial blood gases (ABGs) is the priority assessment because heroin toxicity can lead to respiratory depression and impaired gas exchange. ABGs provide crucial information about the client's oxygenation and ventilation status, which is essential for managing mechanical ventilation and preventing respiratory complications. Monitoring urine output (
A) is important but not the priority in a client with potential respiratory compromise. Assessing level of consciousness (
B) is significant, but ensuring adequate oxygenation takes precedence. Monitoring for signs of withdrawal (
D) is important but not as urgent as assessing respiratory status.