ATI RN
RN ATI Adult Medsurg Proctored Exam 2023 With NGN Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has deep-vein thrombosis and is receiving heparin via continuous IV infusion. The clients weight is 80 kg (176.4 lb). Using the client information provided, which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Stop the heparin infusion for 1 hr. This is because the client's weight is crucial in determining the appropriate heparin dosage. Heparin is usually dosed based on the client's weight to prevent complications such as bleeding or clotting. In this case, the client's weight of 80 kg indicates a specific dose range for heparin. Stopping the infusion for 1 hour allows the nurse to reassess the client's condition and potentially adjust the heparin dosage to ensure it is safe and effective.
A: Increasing the infusion rate without proper assessment can lead to overdose and increased risk of bleeding.
B: Administering protamine sulfate is the antidote for heparin overdose, not indicated in this scenario.
D: Decreasing the heparin dose without assessment may result in inadequate anticoagulation and increased risk of clot formation.
Question 2 of 5
A nurse is caring for a client who is 3 hr postoperative and exhibiting signs of hypovolemia. Which of the following findings should the nurse identify as a manifestation of hypovolemia?
Correct Answer: A
Rationale: The correct answer is A: Rapid pulse rate. Following surgery, hypovolemia can occur due to fluid loss. A rapid pulse rate is a common manifestation of hypovolemia as the body compensates for decreased blood volume by increasing heart rate to maintain perfusion. Bradycardia (
B) is unlikely with hypovolemia as the body tries to increase cardiac output. Hypertension (
C) is not typical in hypovolemia as blood pressure tends to decrease. Peripheral edema (
D) is associated with fluid overload, not hypovolemia.
Question 3 of 5
A nurse is assessing a clients ECG strip and notes an irregular heart rate of 98/min with no clear P waves. Which of the following cardiac dysrhythmias should the nurse document?
Correct Answer: B
Rationale: The correct answer is B: Atrial fibrillation. In atrial fibrillation, the heart rate is irregular and fast (98/min), and there are no clear P waves on the ECG strip, which aligns with the findings in the scenario. Atrial fibrillation is characterized by chaotic electrical activity in the atria, leading to an irregular heart rate. Sinus bradycardia (
A) is characterized by a slow heart rate with normal P waves. Ventricular tachycardia (
C) is a fast heart rhythm originating in the ventricles with distinct QRS complexes. First-degree heart block (
D) is identified by a prolonged PR interval but should still have clear P waves. Other choices are not relevant. In this case, the absence of clear P waves and irregular heart rate point towards atrial fibrillation as the correct dysrhythmia to document.
Question 4 of 5
A nurse is inspecting the skin of a client who has basal cell carcinoma. The nurse should identify which of the following lesion characteristics on the clients skin?
Correct Answer: A
Rationale: The correct answer is A: A pearly, waxy nodule. Basal cell carcinoma typically presents as a pearly, waxy nodule on the skin. This characteristic appearance is due to the growth of abnormal cells in the basal cell layer of the skin. The nodule may also have small blood vessels visible on its surface. This presentation is distinct from other skin lesions.
Choice B, a scaly red patch, is more indicative of conditions like psoriasis or eczema.
Choice C, a dark irregular mole, is more suggestive of melanoma.
Choice D, a firm, painless lump, is more characteristic of conditions like lipomas or fibromas. Thus, the correct answer is A based on the specific characteristics of basal cell carcinoma.
Question 5 of 5
A nurse is assessing a client who is undergoing radiation therapy for breast cancer. Which of the following findings is an indication to the nurse that the client is experiencing an adverse effect of the therapy?
Correct Answer: A
Rationale: The correct answer is A: Skin changes. This is because skin changes, such as redness, irritation, or peeling, are common adverse effects of radiation therapy. The skin over the treated area may become sensitive and may develop a sunburn-like appearance. This indicates that the radiation is affecting the skin cells. Hypertension (
B), diarrhea (
C), and increased white blood cell count (
D) are not typically associated with adverse effects of radiation therapy for breast cancer. Hypertension may be related to stress or other factors, diarrhea could be due to other causes, and an increased white blood cell count is not a typical adverse effect of radiation therapy.