ATI RN
ATI RN Adult Medical Surgical 2023 Questions Questions
Extract:
Question 1 of 5
A nurse is assessing a client who is postoperative following a transurethral resection of the prostate and is receiving continuous bladder irrigation. The client reports bladder spasms, and the nurse notes a scant amount of fluid in the urinary drainage bag, which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Use 0.9% sodium chloride to perform an intermittent bladder irrigation. In this scenario, the client is experiencing bladder spasms and a scant amount of fluid in the drainage bag, indicating a potential blockage or clot in the catheter. Performing an intermittent bladder irrigation with 0.9% sodium chloride can help to clear the catheter and improve urine flow. This intervention helps prevent further complications such as urinary retention or infection. Encouraging the client to unseat or applying a cold compress may not address the underlying issue of catheter blockage. Securing the catheter to the upper left quadrant does not directly address the current problem and may not improve urine flow.
Question 2 of 5
A nurse is caring for a client who is postoperative following a below-the-knee amputation. Which of the following statements made by the client indicates acceptance of their altered body image?
Correct Answer: A
Rationale: The correct answer is A because the statement indicates the client's willingness to connect with someone who has undergone a similar experience, showing acceptance and readiness to learn from others in similar situations. This demonstrates the client's acknowledgment of their altered body image and a proactive approach towards coping with it positively.
Choice B reflects avoidance behavior, not acceptance.
Choice C focuses on the relief of pain rather than acceptance of body image changes.
Choice D suggests resignation rather than acceptance.
Question 3 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 4 of 5
A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily for 3 years. Which of the following tests should the nurse monitor?
Correct Answer: B
Rationale: The correct answer is B: Stool for occult blood. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAI
D) that can cause gastrointestinal bleeding, leading to occult blood in the stool. Monitoring stool for occult blood helps in detecting any gastrointestinal bleeding early. Serum calcium (
A) is not typically affected by long-term ibuprofen use. Fasting blood glucose (
C) is not directly related to ibuprofen use. Urine for white blood cells (
D) is not relevant in this scenario.
Extract:
Medical History: Cerebrovascular accident (CVA) 2 years ago, Coronary artery disease, Hypertension, Hyperlipidemia. A nurse is reviewing the client's medical record. After reviewing the medical history, the nurse must determine which of the following actions to take.
Question 5 of 5
For each potential provider’s prescription, the nurse must select if the action is Anticipated, Nonessential, or Contraindicated for the client.
| Potential Prescription | Anticipated | Non-essential | Contraindicated |
|---|---|---|---|
| Encourage the client to cough | |||
| Elevate the head of the bed | |||
| Assist the client to the bathroom | |||
| Decrease oxygen to 1.5 L/min via nasal cannula | |||
| Keep the client’s head in a midline position | |||
| Initiate seizure precautions |
Correct Answer: B, A, C, A
Rationale: The correct answer is based on the rationale below:
1. Elevate the head of the bed (
B): This action is Anticipated as it helps prevent aspiration and promotes optimal respiratory function.
2. Encourage the client to cough (
A): Also Anticipated as coughing helps clear secretions and maintain airway patency.
3. Assist the client to the bathroom (
C): This is Non-essential unless there are specific concerns about the client's mobility or urgency.
4. Decrease oxygen to 1.5 L/min via nasal cannula (
A): Contraindicated as it may compromise oxygenation, especially without proper assessment and orders.
Other choices:
- Keeping the client's head in a midline position (E) is not provided in the question stem, so it cannot be evaluated.
- Initiating seizure precautions (F) is not relevant to the client's immediate care based on the information given