ATI RN
RN ATI Adult Medsurg Proctored Exam 2023 With NGN Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions should the nurse implement to decrease the clients risk for ventilator-associated pneumonia (VAP)? (Select all that apply.)
Correct Answer: B, C, E
Rationale:
Correct Answer: B, C, E
Rationale:
- Monitoring for oral secretions every 2 hr helps prevent aspiration of secretions, reducing the risk of VAP.
- Providing oral care every 2 hr reduces the bacterial load in the mouth, decreasing the risk of VAP.
- Assessing the client daily for readiness of extubation allows for timely removal of the ventilator, reducing the duration of ventilation and lowering the risk of VAP.
Incorrect
Choices:
- Wearing a protective gown when suctioning the client's airway does not directly decrease the risk of VAP.
- Maintaining the client in a supine position may increase the risk of aspiration and VAP.
Question 2 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 Cushings 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 classic sign of increased intracranial pressure (ICP), seen in traumatic brain injury. It consists of hypertension (elevated blood pressure), bradycardia (not tachycardia), and irregular respirations (not rapid shallow respirations). The increase in blood pressure is due to the body's attempt to maintain cerebral perfusion in response to the increased ICP. The other choices are incorrect because they do not align with the classic presentation of Cushing's triad in traumatic brain injury.
Question 3 of 5
A nurse is caring for a client who is hemorrhaging and hypotensive from esophageal variceal bleeding. Which of the following actions should the nurse take first?
Correct Answer: B
Rationale: The correct answer is B: Verify that the client has adequate IV access. This is the priority action because the client is hypotensive from hemorrhaging, indicating a need for immediate fluid resuscitation to stabilize their condition. Without adequate IV access, the nurse cannot administer life-saving fluids and medications. Administering a vasopressor (
A) or preparing for endoscopic intervention (
D) may be necessary later but addressing the hypotension is the priority. Placing the client in Trendelenburg position (
C) is not recommended as it can increase intracranial pressure.
Question 4 of 5
A nurse notes that a clients eyes are protruding slightly from their orbits. Which of the following laboratory findings should the nurse expect?
Correct Answer: B
Rationale: The nurse should expect increased T4 levels in a client with slightly protruding eyes, known as exophthalmos, as it is a classic sign of hyperthyroidism, where the thyroid gland is overactive. Thyroid hormones, such as T4, are responsible for regulating metabolism, and elevated levels can lead to symptoms like exophthalmos. Decreased TSH levels (choice
A) would actually be seen in primary hyperthyroidism due to negative feedback. Elevated calcium levels (choice
C) are more indicative of hyperparathyroidism. Low hemoglobin levels (choice
D) are not typically associated with exophthalmos or hyperthyroidism.
Question 5 of 5
A nurse is caring for a client who has multiple leg fractures and is 24 hr postoperative following placement of skeletal traction. Which of the following actions should the nurse take?
Correct Answer: A
Rationale:
Correct Answer: A. Inspect the pin sites at least every 8 hr.
Rationale:
1. Inspecting pin sites regularly is crucial to monitor for signs of infection or other complications.
2. Postoperative clients with skeletal traction are at high risk for pin site infections.
3. Regular inspection allows early detection and intervention to prevent complications.
4. Waiting longer than every 8 hours may lead to delayed identification of issues.
Summary:
B. Applying direct pressure is contraindicated as it can cause harm.
C. Removing traction weights without medical order can lead to complications.
D. Encouraging vigorous movement is inappropriate and can cause harm.