ATI RN
ATI Adult Medical Surgical 2019 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has bounding pulses, crackles on auscultation, and pink frothy secretions when receiving suctioning. The nurse should recognize these assessment findings as indicating which of the following?
Correct Answer: C
Rationale: Bounding pulses, crackles, and pink frothy secretions indicate fluid volume excess, often due to heart failure causing pulmonary edema. Increased cardiac output, pleural effusion, and aspiration do not typically present with these findings.
Question 2 of 5
A nurse is caring for a client who has a traumatic brain injury. The client, who has been quiet and cooperative, becomes agitated and restless. Which of the following assessments should the nurse perform first?
Correct Answer: D
Rationale: Agitation and restlessness in traumatic brain injury may indicate increased intracranial pressure, often accompanied by elevated blood pressure, making it the first assessment.
Question 3 of 5
A nurse is assessing a client who has right-sided heart failure. Which of the following assessment findings should the nurse expect to find?
Correct Answer: B
Rationale: Pitting edema is a hallmark of right-sided heart failure due to fluid retention in the extremities. Poor skin turgor, oliguria, and S4 sounds are not typical findings.
Question 4 of 5
A nurse is caring for a client who has a chest tube. The client asks why the fluid in the water-seal chamber rises and falls. Which of the following statements should the nurse make?
Correct Answer: C
Rationale: The rise and fall (tidaling) in the water-seal chamber is caused by normal respiratory pressure changes. Air leaks, full lung expansion, or high suction do not cause tidaling.
Question 5 of 5
A nurse is caring for a client who has hypotension, cool and clammy skin, tachycardia, and tachypnea. In which of the following positions should the nurse place the client?
Correct Answer: C
Rationale: Elevating the feet improves blood flow to vital organs in hypovolemic shock. High-Fowler's, side-lying, and Reverse Trendelenburg do not address hypotension effectively.