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 is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct action to take first when caring for a client experiencing a seizure is to clear items from the client's surrounding area (
Choice
D). This is important to prevent injury to the client during the seizure. By removing objects that could cause harm, such as sharp or hard items, the nurse ensures a safe environment for the client. Lowering the client to the floor (
Choice
A) is important but should be done after clearing the surroundings to prevent injury. Obtaining vital signs (
Choice
B) and loosening restrictive clothing (
Choice
C) can be done after ensuring the safety of the environment. Thus, the priority is to clear items from the client's surrounding area to prevent harm during the seizure.
Question 3 of 5
A nurse is providing discharge teaching to a client who is postoperative following a total hip arthroplasty. Which of the following statements should the nurse make?
Correct Answer: B
Rationale: The correct answer is B: Use a raised toilet seat to maintain your hips above your knees. This is important post-total hip arthroplasty to prevent hip dislocation. By keeping the hips above the knees, it reduces stress on the hip joint.
Incorrect choices:
A: Twisting at the waist can strain the hip joint post-surgery.
C: Applying heat can increase inflammation and risk of infection.
D: Moving the stronger leg first can lead to uneven weight distribution, increasing the risk of falls.
Question 4 of 5
A nurse is caring for a client who has diabetes mellitus and has been following a treatment plan for 3 months. Which of the following laboratory results should the nurse monitor to determine long-term glycemic control?
Correct Answer: B
Rationale: The correct answer is B: Glycosylated hemoglobin level. This test provides an average blood glucose level over the past 2-3 months, reflecting long-term glycemic control. Monitoring glycosylated hemoglobin levels helps assess the effectiveness of the client's diabetes management plan over time.
A: Postprandial blood glucose level reflects short-term control after a meal.
C: Fasting blood glucose level reflects current blood glucose levels but not long-term control.
D: Oral glucose tolerance test results evaluate how the body handles glucose, not long-term control.
In summary, monitoring glycosylated hemoglobin levels is crucial for assessing long-term glycemic control in clients with diabetes.
Question 5 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.