ATI RN
RN ATI Adult Medsurg Proctored Exam 2023 With NGN Questions
Extract:
Question 1 of 5
A nurse is caring for a 75-year-old client who is admitted to the medical-surgical unit. Which of the following findings indicate the client is most likely experiencing deep vein thrombosis (DVT)?
Correct Answer: A
Rationale: The correct answer is A. Unilateral right lower extremity swelling and warmth below the knee are classic signs of deep vein thrombosis (DVT). The swelling occurs due to blood clot formation, leading to impaired venous return and warmth due to inflammation.
Choice B is incorrect because pain level alone is not a specific indicator of DVT.
Choice C is incorrect as ambulating with assistance does not directly relate to DVT.
Choice D is incorrect as not wearing sequential compression devices does not definitively indicate DVT.
Question 2 of 5
A nurse is assessing a client who has suspected appendicitis. Which of the following manifestations should the nurse expect? (Select all that apply.)
Correct Answer: A, B, C
Rationale: The correct manifestations for suspected appendicitis are A, B, and C. A is correct as appendicitis typically presents with right lower quadrant pain due to inflammation of the appendix. B is correct as rebound tenderness, which is pain upon release of pressure on the abdomen, is a classic sign of appendicitis. C is correct as nausea and vomiting are common symptoms due to irritation of the gastrointestinal tract. D and E are incorrect as elevated blood glucose and hypotension are not commonly associated with appendicitis.
Question 3 of 5
A nurse is monitoring a client following a lumbar laminectomy. The client has a drain and indwelling urinary catheter. The nurse should identify which of the following findings as an indication of a complication of the surgery?
Correct Answer: C
Rationale: The correct answer is C: Clear drainage on the dressings. Clear drainage may indicate a cerebrospinal fluid leak, which is a serious complication following a lumbar laminectomy. Cerebrospinal fluid is a clear fluid that surrounds the brain and spinal cord, and its leakage can lead to infection and other complications. Red-tinged drainage (choice
A) may be expected initially due to surgical trauma. Cloudy urine in the catheter (choice
B) is more likely related to urinary tract infection. Mild back pain at the surgical site (choice
D) is common after this surgery and does not necessarily indicate a complication.
Question 4 of 5
A nurse is preparing a teaching plan for a client who is starting to receive hemodialysis for chronic kidney disease. Which of the following instructions should the nurse include in the teaching?
Correct Answer: A
Rationale: The correct answer is A: Increase your intake of protein to 1 to 1.5 grams per kilogram per day. This is because patients undergoing hemodialysis often experience protein loss during the process. Adequate protein intake helps maintain muscle mass and supports overall health. Option B is incorrect as fluid restriction is typically recommended for patients on hemodialysis due to impaired fluid removal by the kidneys. Option C is incorrect as increasing sodium intake can lead to fluid retention and exacerbate hypertension, a common complication in chronic kidney disease. Option D is not directly related to hemodialysis and is more pertinent to diabetes management.
Question 5 of 5
A nurse is caring for a client who has deep-vein thrombosis and is receiving heparin via continuous IV infusion. The clients weight is 80 kg (176.4 lb). Using the client information provided, which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Stop the heparin infusion for 1 hr. This is because the client's weight is crucial in determining the appropriate heparin dosage. Heparin is usually dosed based on the client's weight to prevent complications such as bleeding or clotting. In this case, the client's weight of 80 kg indicates a specific dose range for heparin. Stopping the infusion for 1 hour allows the nurse to reassess the client's condition and potentially adjust the heparin dosage to ensure it is safe and effective.
A: Increasing the infusion rate without proper assessment can lead to overdose and increased risk of bleeding.
B: Administering protamine sulfate is the antidote for heparin overdose, not indicated in this scenario.
D: Decreasing the heparin dose without assessment may result in inadequate anticoagulation and increased risk of clot formation.