ATI RN
ATI RN Adult Medical Surgical 2023 III Questions
Extract:
Nurses' Notes
Day 1:
1000:
Client is alert to person, place, and time. Client is short of breath and leans forward to breathe easier. Lung sounds are diminished in bilateral bases with occasional wheezes. Nonproductive cough. Heart rate is regular. +2 pulses in all extremities.
1500:
Client is tachypneic, cough is productive, and mucous is yellow in color. Wheezes and crackles heard upon auscultation. Heart rate is regular. +2 pulses in all extremities. Client is oriented to person, place and time. Client is restless. Pupils are reactive to light. Client is diaphoretic with cyanotic mucous membranes
Vital Signs
1000:
Temperature: 37.1°C (98.8°F)
Heart Rate: 100/min
Respiratory Rate: 22/min (irregular)
Blood Pressure: 164/80 mm Hg
Oxygen Saturation: 92% on room air
1500:
Temperature: 37.3°C (100.3°F)
Heart Rate: 110/min
Respiratory Rate: 26/min (irregular)
Blood Pressure: 110/58 mm Hg
Oxygen Saturation: 87% on room air
Question 1 of 5
A nurse is caring for a client who has COPD. Select the findings below that require immediate follow-up.
Correct Answer: B,C,E,F
Rationale: Restlessness, tachypnea, yellow mucous, and wheezes/crackles indicate worsening COPD requiring intervention.
Extract:
Question 2 of 5
A nurse is caring for a client who has a chest tube in the pleural space. The nurse notices continuous bubbling in the water seal chamber of the client's drainage system. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Continuous bubbling in the water seal chamber indicates an air leak; clamping the tubing helps identify the source.
Question 3 of 5
A nurse is caring for a client in the ICU. The client's ECG monitor tracing reveals sinus bradycardia and ST segment elevation. The client reports shortness of breath and feeling dizzy and faint. Which of the following medications should the nurse administer?
Correct Answer: C
Rationale: Atropine treats symptomatic bradycardia, addressing the client's low heart rate and related symptoms.
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: B
Rationale: The rise and fall of fluid in the water-seal chamber, called tidaling, reflects normal breathing patterns.
Question 5 of 5
A nurse is assessing a client who sustained major full-thickness burns to their lower legs 12 hr ago. Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: Full-thickness burns cause edema due to vascular leakage and tissue damage within the first 12-24 hours.