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 exacerbation of heart failure. Thenurse is assessing the client 24 hr later. How should the nurse interpret the findings related to the diagnosis of heart failure? For each finding, click to specify whe ther the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition. Diagnostic Results Hgb 8.4 g/dL (12 to 18 g/dL) Hct 42% (37% to 47%) WBC count 9,800/mm3 (5,000 to 10,000/ mm3) Potassium 432 mEq/L (3.5 to 5 mEq/L)
| Findings 24 hr later | unrelated to the diagnosis | Potential improvement | Worsening condition |
|---|---|---|---|
| Lung sounds clean | |||
| Creatinine 1.8 mm/dl | |||
| Weight 113kg(249 lb) | |||
| WBC Count 11,800mm3 | |||
| Temperature: 38.5°C (101.3°F) | |||
| Shortness of breath with exertion |
Correct Answer: A, B,C,D,E
Rationale:
The correct answer is A, B, C, D, E. In heart failure exacerbation, key indicators are related to fluid overload and organ perfusion.
A) Lung sounds clean indicate potential improvement in pulmonary congestion.
B) Creatinine 1.8 mm/dl is important for kidney function monitoring, as worsening kidney function can occur in heart failure.
C) Weight 113kg reflects fluid retention, relevant for heart failure management.
D) WBC count (11,800mm3) can indicate infection, which can worsen heart failure. E) Temperature 38.5°C can suggest infection or systemic inflammatory response, which worsens heart failure.
Question 2 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 3 of 5
A nurse is providing teaching for a client who has diabetes mellitus about the self-administration of insulin.The client has prescriptions for regular and NPH insulins. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: A
Rationale:
Correct
Answer: A: I will draw up the regular insulin into the syringe first.
Rationale: Drawing up regular insulin first is crucial for preventing contamination between the two insulins. Regular insulin is a clear solution and should be drawn up first to prevent any cloudiness or contamination from the NPH insulin, which is a cloudy suspension. Drawing up regular insulin first ensures accuracy in dosing and prevents mixing of the two insulins.
Incorrect
Choices:
B: Shaking the NPH vial vigorously before drawing up the insulin is incorrect as it can cause bubbles and affect the accuracy of the dose.
C: Storing prefilled syringes in the refrigerator with the needle pointed downward is incorrect as it can lead to leakage or contamination.
D: Inserting the needle at a 15-degree angle is incorrect as insulin injections should be administered at a 90-degree angle for proper absorption.
Question 4 of 5
A nurse is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement?
Correct Answer: C
Rationale: The correct answer is C: Use a bed alarm. This is the most appropriate action to help prevent the client from wandering and ensure their safety. A bed alarm will alert the nurse when the client tries to get out of bed, allowing for timely intervention. Moving the client to a double room (
A) may not necessarily prevent wandering. Using chemical restraints (
B) is not recommended due to ethical concerns and potential adverse effects. Encouraging excessive stimulation (
D) may increase agitation and wandering behavior.
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.]