ATI RN
ATI n269 Med Surg Comprehensive Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: The first action should be to check the client's vital signs. Nausea and weakness are common symptoms of digoxin toxicity, which can cause bradycardia, arrhythmias, and other life-threatening complications. Checking the vital signs, particularly the heart rate, is critical to assess if the client is experiencing digoxin toxicity.
Question 2 of 5
A nurse on a telemetry unit is caring for a client who has unstable angina and is reporting chest pain with a severity of 6 on a 0 to 10 scale. The nurse administers 1 sublingual nitroglycerin tablet. After 5 min, the client states that his chest pain is now a severity of 2. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Obtaining an ECG is the appropriate action to assess for any changes in the heart's electrical activity that may indicate worsening ischemia or other complications, such as a myocardial infarction. Even though the pain has decreased, it is important to evaluate the underlying cause of the chest pain, particularly with unstable angina.
Question 3 of 5
A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make?
Correct Answer: B
Rationale: Warfarin takes several days to reach a therapeutic effect, so heparin is continued initially to provide immediate anticoagulation until the warfarin becomes effective.
Question 4 of 5
A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: The first action should be to check the client's vital signs. Nausea and weakness are common symptoms of digoxin toxicity, which can cause bradycardia, arrhythmias, and other life-threatening complications. Checking the vital signs, particularly the heart rate, is critical to assess if the client is experiencing digoxin toxicity.
Question 5 of 5
The nurse plans of care for a patient who has a fractured femur. During the 24 to 48 hours after the fracture, the nurse monitors the patient for the development of which complication?
Correct Answer: B
Rationale: Fat embolism syndrome (FES) is a serious complication that can occur within 24 to 48 hours after a long bone fracture, especially a femur fracture. Fat droplets from the bone marrow can enter the bloodstream, leading to embolism in the lungs, brain, or heart, causing symptoms such as respiratory distress, confusion, and petechial rash.