ATI RN
ATI Med Surg exam 2 III Questions
Extract:
Question 1 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 2 of 5
A nurse is providing teaching to a client who has a family history of hypertension. The nurse should inform the client that his blood pressure of 124/85 mm Hg places him in which of the following categories?
Correct Answer: B
Rationale: Blood pressure of 124/85 mm Hg falls within the elevated (prehypertension) category, defined as systolic 120-129 mm Hg and diastolic less than 80 mm Hg.
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 teaching a newly licensed nurse about evaluating a cardiac rhythm. Which of the following options should the nurse identify as the P wave in the ECG complex?
Correct Answer: A
Rationale: The first upward deflection in an ECG represents the P wave, indicating atrial depolarization. It precedes the QRS complex and corresponds to the electrical activity associated with atrial contraction, initiating the cardiac cycle.
Question 5 of 5
A nurse is teaching a newly licensed nurse about evaluating a cardiac rhythm. Which of the following options should the nurse identify as the P wave in the ECG complex?
Correct Answer: A
Rationale: The first upward deflection in an ECG represents the P wave, indicating atrial depolarization. It precedes the QRS complex and corresponds to the electrical activity associated with atrial contraction, initiating the cardiac cycle.