ATI RN
ATI RN Adult Medical Surgical 2023 V Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg, a fluid intake of 960 mL, and an output of 300 mL in the past 12 hr. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Dyspnea and fluid overload signs suggest slowing the infusion and notifying the provider to prevent worsening heart failure.
Question 2 of 5
A nurse is caring for a client who has a chest tube. The client asks why the fluid in the water-seal chamber rises and falls. Which of the following statements should the nurse make?
Correct Answer: B
Rationale: The rise and fall (tidaling) in the water-seal chamber reflect normal respiratory pressure changes during breathing.
Extract:
History and Physical
1000:
Client reports after eating breakfast this morning at 0630 that they began feeling tightness in chest that radiates to left arm. History:
Hyperlipidemia, hypertension, type 2 diabetes mellitus. Non-smoker. Denies use of alcohol or recreational drug use.
Nurses' Notes
1000:
Client reports tightness in chest that radiates to left arm. States pain as 7 on a scale of 0 to 10. Started to feel nauseous after breakfast. Client states, "I had scrambled eggs and bacon like I do every morning." Client is diaphoretic and short of breath. Heart rate irregular and tachycardic. Alert and oriented to person, place, and time. Lungs clear to auscultation in all lobes. Bowel sounds are present in all 4 quadrants. +1 pedal pulses. Skin is cool to touch. Capillary refill less than 2 seconds.
Vital Signs
1000:
• Temperature 37.1° C (98.8° F)
• Heart rate 110/min and irregular
• Respiratory rate 24/min
• Blood pressure 164/80 mm Hg
• Oxygen saturation 93% on room air
Diagnostic Results
1000:
• Myoglobin 100 mcg/L (less than 90 mcg/L)
• Creatine kinase 180 units/L (55 to 170 units/L)
• Troponin T 0.40 ng/mL (less than 0.1 ng/mL)
• Troponin 10.35 ng/mL (less than 0.03 ng/mL)
• Cholesterol 244 mg/dL (less than 200 mg/dL)
• Triglycerides 180 mg/dL (40 to 160 mg/dL)
• LDL cholesterol 148 mg/dL (less than 130 mg/dL)
• HDL cholesterol 42 mg/dL (greater than 45 mg/dL)
• C-reactive protein 2 mg/mL (less than 1.0 mg/mL)
• Blood glucose 103 mg/dL (74 to 106 mg/dL)
12-lead electrocardiogram: tachycardia with ST segment elevation and T wave changes
Chest x-ray: lungs are clear in all lobes
Provider prescriptions
1020:
• Nitroglycerin 0.5 mg SL may repeat every 5 min up to 3 doses as needed for chest pain
• Aspirin 160 mg PO daily
• Morphine 6 mg IV bolus every 3 hr PRN pain
• Metoprolol 25 mg PO every 6 hr x 48 hr, then metoprolol 100 mg PO twice daily
• Initiate peripheral IV site
• 0.9% sodium chloride 50 mL/hr by continuous IV infusion
• Oxygen at 2 L/min via nasal cannula if oxygen saturation is less than 90%
• Schedule stat echocardiogram
• 2 g sodium diet
Question 3 of 5
A nurse is admitting a client who reports tightness in their chest that radiates to left arm. The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up.
Correct Answer: C,D,E,G
Rationale: Elevated blood pressure, pain, ECG changes, and troponin indicate myocardial infarction needing urgent intervention.
Extract:
Question 4 of 5
A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: Lowering the client to the floor prevents injury from falling, the priority during a seizure.
Question 5 of 5
A nurse is providing teaching to a client who is to start furosemide therapy for heart failure. Which of the following statements indicates that the client understands a potential adverse effect of this medication?
Correct Answer: C
Rationale: Limiting salt helps prevent fluid retention, a side effect furosemide manages in heart failure.