ATI RN
ATI RN Adult Medical Surgical 2023 Questions Correct Answers Questions
Extract:
Exhibit 1- Medical History,
Dehydration, Hyperlipidemia, Hypertension, Coronary artery disease (CAD) Exhibit 2-
Diagnostic Results
WBC count 14,000/mm° (5,000 to 10,000/mm)
Hgb 14 g/dL (12 to 16 g/dL)
Hct 40% (34 to 47%)
Sodium 132 mEq/L (136 to 146 mEq/L)
Potassium 6.2 mEq/L (3.5 to 5 mEq/L)
Question 1 of 5
A nurse is caring for a client receiving TPN. Which of the following actions should the nurse take? For each potential nursing intervention, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client.
| Nursing Intervention | Anticipated | Non-essential | Contraindicated |
|---|---|---|---|
| Request a prescription for insulin | |||
| Request for an antibitic to be administered | |||
| Decrease the client's oxygen to 1.5 L/min via nasal canula | |||
| Have 3 nurses verify the TPN solution prescription | |||
| Notify the provider to increase TPN rate/hr |
Correct Answer: A,B,C,D
Rationale: [
Anticipated: Request a prescription for insulin, Request for an antibiotic to be administered, Decrease the client's oxygen to 1.5 L/min via nasal cannula, Have 3 nurses verify the TPN solution prescription.
Rationale: A client on TPN may require insulin for glycemic control, antibiotics for infection management, oxygen adjustment for respiratory support, and verification of TPN solution to prevent errors.
Non-essential/Contraindicated: Not applicable as all options are essential in the care of a client receiving TPN.]
Extract:
Question 2 of 5
A nurse is caring for a client who has chronic venous insufficiency. Which of the following areas should the nurse assess for the presence of a venous ulcer?
Correct Answer: B
Rationale: The correct answer is B: Medial malleolus (ankle). Venous ulcers commonly occur in the lower legs, particularly around the medial malleolus due to poor circulation in chronic venous insufficiency. The pressure and pooling of blood in the veins can lead to tissue breakdown and ulcer formation in this area. Assessing the medial malleolus for the presence of a venous ulcer is crucial in managing the client's condition.
Incorrect
Choices:
A: Tip of the toes - Venous ulcers are less likely to occur in this area as it is more distal and less affected by venous insufficiency.
C: Ball of the foot - Venous ulcers are more commonly found in the lower legs rather than the ball of the foot.
D: Heel of the foot - While ulcers can develop on the heel, they are less likely to be venous ulcers in chronic venous insufficiency compared to the medial malleol
Question 3 of 5
A nurse is caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings should the nurse identify as an indication that the medication was effective?
Correct Answer: A
Rationale: The correct answer is A: Decreased anxiety. Morphine is often used to relieve pain and anxiety in patients with acute heart failure. The nurse should expect a reduction in anxiety as a positive response to the medication. Emesis (choice
B) is not a typical indication of morphine effectiveness. Increased respiratory rate (choice
C) may indicate respiratory depression, a potential adverse effect of morphine. Decreased urinary output (choice
D) could suggest decreased cardiac output, which is not necessarily a sign of morphine effectiveness in this case.
Question 4 of 5
A nurse is caring for a client who is experiencing an exacerbation of heart failure. Thenurse is assessing the client 24 hr later. How should the nurse interpret the findings related to the diagnosis of heart failure? For each finding, click to specify whe ther the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition. Diagnostic Results Hgb 8.4 g/dL (12 to 18 g/dL) Hct 42% (37% to 47%) WBC count 9,800/mm3 (5,000 to 10,000/ mm3) Potassium 432 mEq/L (3.5 to 5 mEq/L)
| Findings 24 hr later | unrelated to the diagnosis | Potential improvement | Worsening condition |
|---|---|---|---|
| Lung sounds clean | |||
| Creatinine 1.8 mm/dl | |||
| Weight 113kg(249 lb) | |||
| WBC Count 11,800mm3 | |||
| Temperature: 38.5°C (101.3°F) | |||
| Shortness of breath with exertion |
Correct Answer: A, B,C,D,E
Rationale:
The correct answer is A, B, C, D, E. In heart failure exacerbation, key indicators are related to fluid overload and organ perfusion.
A) Lung sounds clean indicate potential improvement in pulmonary congestion.
B) Creatinine 1.8 mm/dl is important for kidney function monitoring, as worsening kidney function can occur in heart failure.
C) Weight 113kg reflects fluid retention, relevant for heart failure management.
D) WBC count (11,800mm3) can indicate infection, which can worsen heart failure. E) Temperature 38.5°C can suggest infection or systemic inflammatory response, which worsens heart failure.
Question 5 of 5
A nurse is monitoring a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a manifestation of Cushing's triad?
Correct Answer: A
Rationale: The correct answer is A: Increase in blood pressure from 130/80 mm Hg to 180/100 mm Hg. Cushing's triad is a set of three classic signs indicating increased intracranial pressure (ICP). The triad includes hypertension (widening pulse pressure), bradycardia, and irregular respirations. In this case, an increase in blood pressure is consistent with the hypertension component of Cushing's triad. This occurs due to the body's compensatory mechanism to maintain perfusion to the brain in response to increased ICP.
Choices B, C, D, and E do not align with the classic signs of Cushing's triad. Bradycardia, not a decrease in heart rate, is typically seen in Cushing's triad. Rapid and shallow respirations are not part of the triad. Hypotension is not a characteristic finding in Cushing's triad.