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 morphine through a PCA device. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Teaching the client to use the PCA ensures safe, patient-controlled pain management.
Question 2 of 5
A nurse in the PACU is caring for a client following a thyroidectomy. Which of the following findings should the nurse report to the provider?
Correct Answer: D
Rationale: Dyspnea post-thyroidectomy may indicate airway obstruction or hematoma, a critical finding requiring immediate reporting.
Question 3 of 5
A nurse is planning care for a client who is receiving heparin IV to treat a pulmonary embolism. Which of the following medications should the nurse plan to have available?
Correct Answer: A
Rationale: Protamine sulfate reverses heparin's anticoagulant effect in case of bleeding, essential for heparin therapy.
Question 4 of 5
A nurse is administering furosemide 80 mg PO twice daily to a client who has pulmonary edema. Which of the following assessment findings indicates to the nurse that the medication is effective?
Correct Answer: C
Rationale: Weight loss indicates fluid loss, showing furosemide's effectiveness in reducing pulmonary edema.
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 5 of 5
A nurse is reviewing the client's diagnostic results and vital signs. Which of the following actions should the nurse take? Select all that apply.
Correct Answer: A,B,E
Rationale: Cardiac catheterization is indicated for ST-elevation, heparin prevents further clotting, and NPO status prepares for procedures.