ATI RN
ATI Advanced Med Surg Exam 3 Questions
Extract:
Question 1 of 5
A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?
Correct Answer: B
Rationale: Muffled heart sounds, part of Beck's triad, indicate fluid accumulation in the pericardial sac, supporting cardiac tamponade.
Question 2 of 5
Which assessment finding by the nurse caring for a patient receiving mechanical ventilation indicates the need for suctioning?
Correct Answer: D
Rationale: A drop in oxygen saturation to 93% suggests airway obstruction or secretions, indicating the need for suctioning.
Question 3 of 5
A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make?
Correct Answer: C
Rationale: Low CVP indicates reduced venous return, consistent with hypovolemia from trauma-related blood loss.
Extract:
Four hours after her arrival to the emergency department, the patient remains in second-degree type II heart block and her vital signs are stable. She is transferred to a telemetry unit to prepare for insertion of a permanent pacemaker later in the day. When she gets out of bed to use the restroom, she felt faint and had to sit on the floor. The nurse finds her sitting on the floor beside the commode; the patient is awake but somewhat confused. The nurse notes that the ECG monitor shows that the patient's heart rate is at 40 beats/minute and she is now in third degree heart block. The Rapid Response team is called, and preparations are made for the immediate application of a transcutaneous pacemaker (TCP).
Question 4 of 5
Which nursing actions should be included in the plan of care for the patient (Select All that Apply.)
Correct Answer: B,C,D,E,F
Rationale: Monitoring vital signs and ECG ensures stability, reassurance reduces anxiety, atropine may be used for bradycardia, proper pad placement ensures effective pacing, and analgesia addresses discomfort.
Extract:
Question 5 of 5
A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?
Correct Answer: D
Rationale: A pulse deficit between apical and radial pulses indicates irregular ventricular contractions typical of atrial fibrillation.