ATI RN
ATI RN Adult Medical Surgical 2023 Questions Correct Answers Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is experiencing an increase in intracranial pressure (ICP). The nurse should expect which of the following as an early manifestation of increased ICP?
Correct Answer: C
Rationale: The correct answer is C: Restlessness. In early stages of increased ICP, the brain tries to compensate by increasing blood flow to maintain perfusion, leading to restlessness. Projectile vomiting (
A) is a late sign due to pressure on the vomiting center. Decorticate posturing (
B) and papilledema (
D) are late signs of increased ICP.
Question 2 of 5
A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Photophobia. Meningitis is an inflammation of the meninges, the protective membranes covering the brain and spinal cord. Photophobia, or sensitivity to light, is a classic symptom of meningitis due to the irritation of the meninges causing increased sensitivity to light. This occurs because the inflamed meninges lead to stimulation of the nerves around the brain, resulting in discomfort when exposed to light.
Bradycardia (
B) is not typically associated with meningitis. Intermittent headache (
C) is vague and can be present in various conditions. Petechiae on the chest (
D) are more commonly seen in conditions like meningococcal meningitis.
Question 3 of 5
A nurse is caring for a client who has heart failure. Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing _________ and_________ Word choices: dysrhythmias, respiratory alkalosis, acute kidney injury, fluid volume
Correct Answer: A
Rationale: The correct answer is A: Dysrhythmias. In heart failure, the reduced cardiac output can lead to inadequate perfusion, causing the heart to work harder, increasing the risk of dysrhythmias. Dysrhythmias are common in heart failure due to changes in the heart's structure and function. Respiratory alkalosis is less likely in heart failure as it is more commonly associated with conditions like hyperventilation. Acute kidney injury can occur in heart failure due to poor perfusion, but it is not directly related to the risk stated. Fluid volume deficit is not the typical risk in heart failure as patients usually have fluid retention.
Question 4 of 5
A nurse is assessing a client who is 4 hr postoperative following arterial revascularization of the left femoral artery. Which of the following findings should the nurse report to the provider immediately?
Correct Answer: B
Rationale: The correct answer is B: Pallor in the affected extremity. Pallor in the affected extremity post arterial revascularization could indicate compromised blood flow, potentially leading to ischemia or thrombosis. This is a critical finding that requires immediate intervention to prevent further complications such as tissue necrosis or limb loss.
Incorrect choices:
A: Temperature elevation may indicate infection, but it is not an immediate concern postoperatively.
C: Bruising around the incisional site is common after surgery and may not require immediate intervention unless there are signs of excessive bleeding.
D: Urine output of 150 mL over 4 hr is within normal limits and not a priority concern in this context.
Question 5 of 5
A nurse is caring for a client who has a small bowel obstruction and an NG tube in place. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Maintain low intermittent suction. This is because in a small bowel obstruction, the NG tube helps decompress the bowel by removing gastric contents and relieving pressure. Low intermittent suction helps prevent excessive suction which can cause tissue damage.
Clamping the NG tube every 2 hours (choice
B) is incorrect as it will prevent the tube from effectively decompressing the bowel. Removing the NG tube immediately (choice
C) is also incorrect as it is needed for decompression. Encouraging high-fiber foods (choice
D) is contraindicated as they can worsen the obstruction.