ATI RN
ATI Med Surg exam 2 III Questions
Extract:
Nurses Notes
Vital Signs
Provider's Prescriptions
0700: Client arrived in the ED complaining of chest discomfort and shortness of breath. Alert and oriented x3. Reports a history of hypertension and diabetes mellitus. Skin is warm and dry. Respirations are 18/min, easy and regular. Oxygen saturation is 91% on room air. Morphine Sulfate 2 mg administered IVP at 0715 for pain management. Client resting in bed, denies pain at this time.
Question 1 of 5
A nurse is caring for a 58-year-old male client in the emergency department (ED) who presents with an irregular pulse and elevated blood pressure. The nurse is planning care for the client. For each potential prescription, indicate whether it is indicated, nonessential, or contraindicated.
| Options | Indicated | Nonessential | Contraindicated |
|---|---|---|---|
| Administer O2 to maintain oxygen saturation greater than 90%. | |||
| Apply continuous ECG monitoring. | |||
| Obtain the client's family history. | |||
| Prepare the client for intubation. |
Correct Answer: A,B
Rationale: Administering O2 to maintain oxygen saturation greater than 90% is indicated to improve tissue oxygenation. Continuous ECG monitoring is crucial for detecting arrhythmias and ischemic changes.
Extract:
Question 2 of 5
A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify Says the nurse clarify?
Correct Answer: A
Rationale: An MRI of the chest is contraindicated in clients with a permanent pacemaker due to the strong magnetic fields, which can interfere with pacemaker function.
Question 3 of 5
A nurse in a clinic is caring for a client who has a prescription for digoxin. Which of the following statements indicates the client is experiencing digoxin toxicity?
Correct Answer: C
Rationale: Digoxin toxicity often manifests as visual disturbances, such as yellow or blurred vision, due to its effect on the central nervous system.
Question 4 of 5
A nurse is caring for a client in the emergency department (ED). The client presents with substernal chest pain that comes and goes. The client states that the pain has been occurring for the last 6 hours. The pain, at times, radiates down the left arm. The client also reports intermittent nausea. The client appears pale and slightly diaphoretic. The client rates current pain as 8 on a scale of 0 to 10. The nurse is planning care for the client. For each potential prescription, indicate whether it is indicated, nonessential, or contraindicated.
| Options | Indicated | Nonessential | Contraindicated |
|---|---|---|---|
| Administering oxygen to maintain oxygen saturation >94%. | |||
| Intubation. | |||
| Continuous ECG monitoring. | |||
| Obtain the client's family history of cardiovascular disease. |
Correct Answer: A,C
Rationale: Administering oxygen to maintain oxygen saturation >94% is indicated to prevent myocardial hypoxia in suspected acute coronary syndrome. Continuous ECG monitoring is essential to detect arrhythmias, ischemia, and ST changes.
Question 5 of 5
A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now he is experiencing a headache. Which of the following statements should the nurse make?
Correct Answer: A
Rationale: Nitroglycerin causes vasodilation, leading to headaches as a common adverse effect. These headaches are due to the increased blood flow and dilation of cerebral blood vessels.