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 acute asthma attack. Which of the following should the nurse identify as a contributing factor to the client's manifestations?
Correct Answer: D
Rationale: The correct answer is D: Inability to exhale retained carbon dioxide. During an acute asthma attack, there is airway obstruction, leading to air trapping and difficulty exhaling. This causes retention of carbon dioxide, leading to respiratory acidosis. This acidosis can further worsen the bronchoconstriction and airway inflammation in asthma.
Choices A, B, and C do not directly contribute to the manifestations of an acute asthma attack. Suppressed bronchiolar inflammatory response (
A) and decreased responsiveness of airways to allergens (
B) would not cause the acute symptoms seen in an asthma attack. Acute loss of alveolar elasticity (
C) is not a primary contributing factor to the acute manifestations of asthma.
Question 2 of 5
A nurse is assessing a client who has a history of type 2 diabetes mellitus. The nurse should identify which of the following findings as an indication of a microvascular complication?
Correct Answer: C
Rationale: The correct answer is C: Retinopathy. In type 2 diabetes, prolonged high blood sugar levels can damage small blood vessels in the retina, leading to retinopathy, a microvascular complication affecting the eyes. This can result in vision problems or even blindness. Peripheral neuropathy (
A) is a macrovascular complication affecting the nerves, not the microvasculature. Hypertension (
B) is a common comorbidity but not a direct microvascular complication. Stroke (
D) is a macrovascular complication involving large blood vessels in the brain, not microvasculature. Thus, the nurse should identify retinopathy (
C) as the correct indication of a microvascular complication in a client with type 2 diabetes mellitus.
Question 3 of 5
Which of the following findings should the nurse identify as a contraindication to receiving this alternative therapy?
Correct Answer: B
Rationale: The correct answer is B: Lymphedema. Lymphedema is a swelling caused by a lymphatic system blockage, which can be worsened by some alternative therapies. Headaches, mouth sores, and urticaria are symptoms that may not necessarily contraindicate alternative therapy. Lymphedema can cause complications if not managed properly, making it a clear contraindication.
Question 4 of 5
A nurse is monitoring a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a manifestation of Cushing's triad?
Correct Answer: A
Rationale: The correct answer is A: Increase in blood pressure from 130/80 mm Hg to 180/100 mm Hg. Cushing's triad is a set of three classic signs indicating increased intracranial pressure (ICP). The triad includes hypertension (widening pulse pressure), bradycardia, and irregular respirations. In this case, an increase in blood pressure is consistent with the hypertension component of Cushing's triad. This occurs due to the body's compensatory mechanism to maintain perfusion to the brain in response to increased ICP.
Choices B, C, D, and E do not align with the classic signs of Cushing's triad. Bradycardia, not a decrease in heart rate, is typically seen in Cushing's triad. Rapid and shallow respirations are not part of the triad. Hypotension is not a characteristic finding in Cushing's triad.
Extract:
Exhibit 1- Medical History,
Dehydration, Hyperlipidemia, Hypertension, Coronary artery disease (CAD) Exhibit 2-
Diagnostic Results
WBC count 14,000/mm° (5,000 to 10,000/mm)
Hgb 14 g/dL (12 to 16 g/dL)
Hct 40% (34 to 47%)
Sodium 132 mEq/L (136 to 146 mEq/L)
Potassium 6.2 mEq/L (3.5 to 5 mEq/L)
Question 5 of 5
A nurse is caring for a client receiving TPN. Which of the following actions should the nurse take? For each potential nursing intervention, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client.
| Nursing Intervention | Anticipated | Non-essential | Contraindicated |
|---|---|---|---|
| Request a prescription for insulin | |||
| Request for an antibitic to be administered | |||
| Decrease the client's oxygen to 1.5 L/min via nasal canula | |||
| Have 3 nurses verify the TPN solution prescription | |||
| Notify the provider to increase TPN rate/hr |
Correct Answer: A,B,C,D
Rationale: [
Anticipated: Request a prescription for insulin, Request for an antibiotic to be administered, Decrease the client's oxygen to 1.5 L/min via nasal cannula, Have 3 nurses verify the TPN solution prescription.
Rationale: A client on TPN may require insulin for glycemic control, antibiotics for infection management, oxygen adjustment for respiratory support, and verification of TPN solution to prevent errors.
Non-essential/Contraindicated: Not applicable as all options are essential in the care of a client receiving TPN.]