ATI RN
ATI Med Surg 2 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse that the client is developing this condition?
Correct Answer: D
Rationale: Breathlessness is a manifestation of left-sided heart failure, caused by pulmonary congestion and edema impairing gas exchange.
Question 2 of 5
A nurse is caring for a client who was admitted with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Providing frequent oral and nares care prevents infection and irritation from the tube.
Question 3 of 5
A nurse is helping to triage a group of clients at a mass casualty incident who were involved in an explosion at a local factory. Which of the following clients should the nurse tag to be the priority for care?
Correct Answer: D
Rationale: This is correct because this client has a life-threatening condition called tension pneumothorax, which requires immediate care. The hissing sound indicates air escaping from the lung, necessitating urgent intervention.
Question 4 of 5
A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?
Correct Answer: B
Rationale: This is correct because increased respiratory rate is an early sign of shock, indicating hypoxia as a compensatory mechanism.
Question 5 of 5
A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?
Correct Answer: C
Rationale: Atrial fibrillation causes irregular palpitations, fatigue, dizziness, and pulse deficit due to ineffective atrial contractions.