ATI RN
ATI RN Adult Medical Surgical 2023 III Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has end-stage liver disease and is being placed on a transplant list. Which of the following statements by the client is the priority for the nurse to report to the provider?
Correct Answer: C
Rationale: Non-adherence to medications can affect transplant eligibility and post-transplant outcomes, making it a priority to report.
Question 2 of 5
A nurse is caring for a client who has end-stage liver disease and is being placed on a transplant list. Which of the following statements by the client is the priority for the nurse to report to the provider?
Correct Answer: C
Rationale: Non-adherence to medications can affect transplant eligibility and post-transplant outcomes, making it a priority to report.
Question 3 of 5
A nurse is caring for a client who is postoperative following a complete thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider?
Correct Answer: C
Rationale: Muscle twitching suggests hypocalcemia, a life-threatening complication post-thyroidectomy due to parathyroid injury.
Question 4 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.
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 5 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.