ATI RN
RN ATI Adult Medsurg Proctored Exam 2023 With NGN Questions
Extract:
Question 1 of 5
A nurse is caring for a client who had a surgical repair of an abdominal aortic aneurysm 3 days ago. The clients vital signs are: temperature 38.3° C (100.9° F), heart rate 80/min, respirations 16/min, and blood pressure 128/76 mm Hg. Which of the following actions is the nurses priority?
Correct Answer: C
Rationale: The correct answer is C: Assess the surgical incision for signs of infection. This is the priority because the client has a fever (indicating possible infection) post-surgery, putting them at risk for complications. Assessing the surgical incision allows for early detection of infection, prompt treatment, and prevention of further complications. Administering an antipyretic (choice
A) only addresses the symptom but not the underlying cause. Encouraging ambulation (choice
B) and increasing IV fluids (choice
D) are important but assessing for infection takes precedence due to the potential severity of an infected surgical site.
Question 2 of 5
A nurse is caring for a client who is 3 hr postoperative and exhibiting signs of hypovolemia. Which of the following findings should the nurse identify as a manifestation of hypovolemia?
Correct Answer: A
Rationale: The correct answer is A: Rapid pulse rate. Following surgery, hypovolemia can occur due to fluid loss. A rapid pulse rate is a common manifestation of hypovolemia as the body compensates for decreased blood volume by increasing heart rate to maintain perfusion. Bradycardia (
B) is unlikely with hypovolemia as the body tries to increase cardiac output. Hypertension (
C) is not typical in hypovolemia as blood pressure tends to decrease. Peripheral edema (
D) is associated with fluid overload, not hypovolemia.
Question 3 of 5
A nurse is caring for a group of clients. In which of the following scenarios is the nurse acting as a client advocate?
Correct Answer: B
Rationale: The correct answer is B because referring a client with COPD for palliative care services demonstrates advocating for the client's best interest, ensuring they receive appropriate care to manage symptoms and improve quality of life. This action aligns with the nurse's role as a client advocate by advocating for the client's autonomy and well-being. In contrast, choices A, C, and D do not prioritize the client's best interests or rights.
Choice A disregards the client's autonomy by encouraging medication against their wishes.
Choice C prioritizes hospital efficiency over the client's needs.
Choice D violates the client's right to informed decision-making by withholding essential information. Overall, choice B best exemplifies client advocacy in nursing practice.
Question 4 of 5
A nurse is assessing a client who takes salmeterol to treat moderate asthma. Which of the following findings should indicate to the nurse that the medication has been effective?
Correct Answer: B
Rationale: The correct answer is B because an increase in the client's daily peak expiratory flow (PEF) by 85% above their personal best indicates improved lung function, which is a positive response to salmeterol. This demonstrates that the medication is effectively managing the asthma symptoms.
Choice A is incorrect because decreased mucus production is not a direct indicator of salmeterol's effectiveness in treating asthma.
Choice C is incorrect as the respiratory rate alone does not provide specific information about the medication's effectiveness.
Choice D is incorrect since the absence of nighttime coughing may be due to various factors and not solely because of salmeterol's effectiveness.
Question 5 of 5
A nurse is assessing a client who has a central venous catheter (CVC) with intravenous (IV) fluids infusing. The client suddenly develops shortness of breath, and the nurse notes that the IV tubing and needleless connector device are disconnected. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Close the pinch clamp on the CVC. This action is crucial to prevent air embolism, a potentially life-threatening complication of central venous catheter disconnection. Closing the pinch clamp will stop air from entering the bloodstream and minimize the risk of air embolism. Administering oxygen (
B) is important, but closing the pinch clamp takes priority to prevent immediate harm. Placing the client in Trendelenburg position (
C) is not recommended as it can worsen air embolism by allowing air to travel to the heart. Obtaining emergency IV access (
D) is not the first priority in this situation; preventing air embolism is critical.