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 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:
Correct Answer: C - Slow infusion rate and contact the provider.
Rationale: The client is showing signs of fluid volume overload with dyspnea, elevated blood pressure, and a significant fluid intake-output discrepancy. Slowing the infusion rate will help reduce fluid intake and potentially prevent worsening of the overload. Contacting the provider is crucial for further assessment and possible adjustment of the treatment plan.
Summary:
A: Lowering the head of the bed may help with respiratory distress but does not address the underlying issue of fluid overload.
B: Administering corticosteroids is not indicated for fluid overload and may worsen the situation.
D: Changing to lactated Ringer's does not address the immediate need to slow down the infusion rate and seek provider guidance.
Question 2 of 5
A nurse in the emergency department is monitoring a client who is receiving dopamine to treat hypovolemic shock. Which of the following findings should the nurse identify as an indication for increasing the client's dopamine dosage?
Correct Answer: A
Rationale: The correct answer is A: Blood pressure 90/50 mm Hg. Dopamine is a vasopressor used to increase blood pressure in hypovolemic shock. A low blood pressure reading of 90/50 mm Hg indicates inadequate perfusion, warranting an increase in dopamine dosage to improve cardiac output. Oxygen saturation (
B) and respiratory rate (
D) are not direct indicators for adjusting dopamine dosage. A heart rate of 60/min (
C) may be within normal limits depending on the client's condition.
Question 3 of 5
A nurse is assessing a client who is 24 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Maintain abduction of the affected extremity. After a total hip arthroplasty, maintaining abduction of the affected extremity helps prevent dislocation of the hip prosthesis. This position helps stabilize the hip joint and reduces the risk of complications. Option B (Position the client in high Fowler's position) is incorrect as it does not directly address the postoperative care specific to a total hip arthroplasty. Option C (Encourage the client to cross their legs at the ankles) is incorrect because crossing legs can create pressure on the hip joint and increase the risk of dislocation. Option D (Have the client bend forward at the waist while sitting) is incorrect as this could also increase the risk of hip dislocation.
Question 4 of 5
A nurse is providing teaching to a client who has a new prescription for levothyroxine to treat hypothyroidism. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: B
Rationale:
Correct Answer: B - If my heart starts racing
Rationale: This statement indicates an understanding of a potential side effect of levothyroxine, which is palpitations or rapid heart rate. It shows that the client is aware of the importance of monitoring for adverse reactions and seeking medical attention if necessary. This is crucial as it can indicate overmedication, which can be harmful.
Incorrect
Choices:
A: Taking levothyroxine with food can interfere with its absorption, reducing its effectiveness.
C: Adjusting the dosage is the healthcare provider's responsibility based on lab results, not the client's decision.
D: Stopping the medication abruptly can lead to a worsening of hypothyroidism symptoms.
E: Taking levothyroxine at night can interfere with sleep patterns and absorption.
Question 5 of 5
A nurse is planning care for a client who is 12 hr postoperative following a kidney transplant. Which of the following actions should the nurse include in the plan of care?
Correct Answer: B
Rationale: The correct answer is B: Assess urine output hourly. This is important postoperatively to monitor kidney function and ensure adequate perfusion. Hourly assessment allows for early detection of any changes in urine output, which can indicate complications such as acute kidney injury. Checking blood pressure every 8 hours (
Choice
A) may be necessary but is less critical in the immediate postoperative period. Administering opioids PO (
Choice
C) can mask changes in the client's condition and should be avoided until kidney function is stable. Monitoring for hypokalemia (
Choice
D) is important but not the priority in the immediate postoperative period.