ATI RN
ATI Nur 221 Med Surg Exam Cardiac Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, 'I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up.' Which of the following actions should the nurse take to help this client with tenacious bronchial secretions?
Correct Answer: A
Rationale: Adequate hydration (2 to 3 L daily) thins mucus secretions, aiding expectoration. Semi-Fowler's position, oxygen therapy, and a low-salt diet do not directly address thick mucus.
Question 2 of 5
What is the underlying rationale for why a nurse assesses a client with emphysema for clinical indicators of hypoxia?
Correct Answer: C
Rationale: Lack of adequate surface area for aeration is correct. Emphysema causes alveolar destruction, reducing gas exchange surface area, leading to chronic hypoxia. Mucus production, infections, and bronchiole inflammation are more relevant to chronic bronchitis or other conditions.
Question 3 of 5
A client comes into the emergency room with complaints of persistent, crushing chest pain. Along with the chief complaint, what other symptoms would make the nurse suspect that the client is experiencing a myocardial infarction (MI)?
Correct Answer: D
Rationale: Diaphoresis and cool clammy skin are correct. These symptoms occur due to sympathetic nervous system activation in response to cardiac ischemia, leading to vasoconstriction, sweating, and signs of impending shock. Intermittent claudication, jugular vein distention, and mid-epigastric pain are not classic MI symptoms.
Question 4 of 5
The nurse is to administer heparin to a client who weighs 90 pounds. Heparin is ordered as 10,000 units/100mL. The nurse needs to administer a bolus of 40units/kg. How many units would the nurse administer? (Round to the nearest tenth)
Correct Answer: C
Rationale: The correct answer is 1636.4 units. Convert 90 pounds to kilograms (90 / 2.2 = 40.91 kg). Calculate the dose: 40.91 kg × 40 units/kg = 1636.4 units. This matches the provided correct answer, so option C (1636.4 units) is correct.
Question 5 of 5
The nurse is assessing the client diagnosed with COPD. Which of the following would require immediate attention by the nurse?
Correct Answer: D
Rationale: Oxygen flowmeter set on 8 LPM is correct. High-flow oxygen can suppress the hypoxic drive in COPD clients, leading to respiratory depression. The nurse should immediately lower the oxygen to a safer level (typically 1-3 LPM) and monitor the client's respiratory status. Use of accessory muscles, thick white sputum, and barrel chest with clubbing are common in COPD but do not require immediate intervention compared to high oxygen flow.