RN ATI Adult Medsurg Proctored Exam 2023 With NGN -Nurselytic

Correct Answer: A

Rationale:
Correct Answer: A: Maintain low intermittent suction.


Rationale: Maintaining low intermittent suction helps to decompress the bowel, reducing the risk of further obstruction. Suction also helps to remove excess fluid and gas from the digestive system, providing relief to the client. It is essential to prevent excessive suction, as it can cause damage to the bowel and worsen the obstruction.

Summary of other choices:
B: Clamping the NG tube every 2 hours is not recommended as it can lead to a buildup of fluid and gas in the bowel, potentially worsening the obstruction.
C: Removing the NG tube immediately is contraindicated as it is necessary for decompression and monitoring of bowel function.
D: Encouraging high-fiber foods is inappropriate in the case of a small bowel obstruction as it can further obstruct the bowel.

Correct Answer: B

Rationale: The correct answer is B: Increased abdominal girth. In right-sided heart failure, the heart is unable to efficiently pump blood to the lungs for oxygenation, leading to fluid backup in the systemic circulation. This results in fluid retention, particularly in the abdomen, causing increased abdominal girth. Crackles in the lungs (choice
A) are indicative of left-sided heart failure. Pink frothy sputum (choice
C) is a sign of pulmonary edema, which is a manifestation of left-sided heart failure. Hypertension (choice
D) is not typically associated with right-sided heart failure.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen using a high-concentration mask. In exertional heat stroke, the body's ability to regulate temperature is compromised, leading to confusion, high temperature, and low blood pressure. Oxygen therapy helps support oxygenation during heat stress. It takes priority to ensure adequate oxygenation and prevent hypoxia, which can worsen the client's condition.

Choices B, C, and D are incorrect. Giving cold fluids orally can potentially induce shock in a hypotensive client. Applying a heating pad can lead to further increase in body temperature. Encouraging the client to walk can exacerbate heat stress and increase the risk of collapse.

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.

Correct Answer: C

Rationale: The correct answer is C: Using an end-tidal CO2 detector. This method is the most reliable for verifying ET tube placement because it directly measures the presence of CO2 in exhaled breath, confirming that the tube is in the trachea. This is crucial to prevent inadvertent esophageal intubation. Observing for symmetrical chest rise and fall (
A) can be misleading as it can occur even with esophageal intubation. Auscultating bilateral breath sounds (
B) can also be unreliable as breath sounds may be heard even if the tube is in the esophagus. Checking for condensation in the ET tube (
D) is not a reliable method for verifying placement as condensation can occur regardless of tube placement.