ATI RN
ATI Medsurg Proctored Final Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?
Correct Answer: A
Rationale: The correct answer is A: Different apical and radial pulses. In atrial fibrillation, the atria quiver instead of contracting effectively, leading to irregular heartbeat and pulse. This results in a discrepancy between the apical (heard by auscultation) and radial (felt at the wrist) pulses. Shortness of breath on exertion (
B), excessive sweating (
C), and systolic blood pressure of 150 mm Hg (
D) are not specific to atrial fibrillation and can occur in various conditions.
Question 2 of 5
During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest. The lesion is raised and flesh-colored with pearly white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer?
Correct Answer: C
Rationale: The correct answer is C: Basal cell carcinoma. Basal cell carcinoma typically presents as a raised, flesh-colored lesion with pearly white borders. This type of skin cancer is the most common and is usually slow-growing with low metastatic potential. It is often found on sun-exposed areas such as the face, neck, and chest. Melanoma (
A) is characterized by asymmetry, irregular borders, varied color, and a diameter larger than 6mm. Squamous cell carcinoma (
B) is usually a firm, red nodule or a flat lesion with a scaly crust. Kaposi's sarcoma (
D) typically presents as purple or blue-black patches or nodules on the skin.
Question 3 of 5
A nurse is assessing a client's wound dressing and observes a watery red drainage. The nurse should document this drainage as which of the following?
Correct Answer: C
Rationale: The correct answer is C: Serosanguineous. This type of drainage is a mixture of clear (serous) and red (sanguineous) fluids, indicating a normal stage of wound healing. The clear fluid suggests minimal inflammation, while the red fluid indicates presence of blood. Serous drainage alone is typically clear and watery without any blood. Sanguineous drainage is bright red and indicates fresh blood. Purulent drainage is thick, opaque, and yellowish-green, suggestive of infection.
Therefore, in this scenario, the observation of watery red drainage best fits the description of serosanguineous drainage.
Question 4 of 5
A nurse is caring for a client with a sucking chest wound from a gunshot. What action should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen via nasal cannula. This is the priority action to ensure the client receives adequate oxygenation. In a sucking chest wound, air enters the pleural space, leading to a potential pneumothorax, which can compromise oxygenation. Administering oxygen helps maintain oxygen saturation levels and supports respiratory function. Placing the client in Trendelenburg position (choice
B) can worsen respiratory distress by increasing pressure on the diaphragm. Applying a warm compress (choice
C) may promote bleeding and is not effective in managing a sucking chest wound. Encouraging deep breathing exercises (choice
D) can further exacerbate the pneumothorax by allowing more air to enter the pleural space.
Question 5 of 5
A nurse is teaching a newly licensed nurse about gynecological examination. Which of the following information should the nurse include in the teaching?
Correct Answer: A
Rationale: The correct answer is A because the urethral orifice is located between the clitoris and the vaginal opening, so separating the labia minora allows for proper visualization and assessment. This step ensures accurate examination of the urethral opening for signs of infection or abnormalities. Palpating the cervix first (
B) is incorrect as it should be done after inspecting the external genitalia. Choosing not to inspect the external genitalia (
C) is incorrect as it is an essential part of the gynecological examination. Assessing the perineum after the vaginal examination (
D) is incorrect as the perineum should be assessed before the vaginal examination to evaluate for any abnormalities or injuries.