ATI RN
ATI Medsurg Proctored Final Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction?
Correct Answer: A
Rationale: The correct answer is A: Perform a 12-lead ECG. This is because an ECG is the most reliable and direct way to assess for myocardial infarction by identifying characteristic changes in the heart's electrical activity. Nitroglycerin (
B) is used to relieve chest pain but should not be administered before confirming the diagnosis. Placing the client in a prone position (
C) is not appropriate for assessing chest pain. Assessing blood pressure (
D) is important but not the initial priority when suspecting myocardial infarction.
Question 2 of 5
A nurse is preparing to initiate a transfusion of packed RBC for a client who has anemia. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Check the client's vital signs every 15 min during the transfusion. This is crucial to monitor for any signs of transfusion reaction, such as fever, chills, or hypotension. Vital signs should be closely monitored initially and then at regular intervals to ensure the client's safety. Checking every 15 minutes allows for early detection and prompt intervention if any adverse reactions occur.
Choice B is incorrect because obtaining a blood pressure reading every 30 minutes is not as frequent as checking vital signs every 15 minutes, which is necessary for early detection of adverse reactions.
Choice C is incorrect as starting the transfusion at a rapid rate can lead to adverse reactions like fluid overload or hemolysis. Transfusions should be started at a slow rate to minimize these risks.
Choice D is incorrect because checking vital signs every hour is not frequent enough to detect early signs of transfusion reactions. Regular monitoring every 15 minutes is recommended for safety.
Question 3 of 5
A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB?
Correct Answer: D
Rationale: The correct answer is D: Sputum culture for acid-fast bacillus. This test is the most reliable for confirming active pulmonary TB because it directly detects the presence of the Mycobacterium tuberculosis bacteria in the sputum sample. Bronchoscopy (
A) may help visualize the airways but does not definitively confirm TB. Chest X-ray (
B) can show characteristic findings suggestive of TB but cannot confirm the diagnosis. TB skin test (
C) indicates exposure but not active disease. Sputum culture is the gold standard for diagnosing TB, as it allows for definitive identification of the bacteria.
Question 4 of 5
A client is teaching a client who has a new prescription for hydrochlorothiazide for management of hypertension. Which of the following instructions should the nurse include?
Correct Answer: A
Rationale:
Rationale: Correct answer is A. Leg cramps are a common side effect of hydrochlorothiazide due to electrolyte imbalance. Monitoring for leg cramps will help in identifying and managing this side effect promptly.
Choices B and D are incorrect as hydrochlorothiazide can lead to electrolyte depletion, so increasing sodium intake is not recommended, and taking the medication at bedtime may increase nighttime urination.
Choice C is incorrect as headaches are not a common side effect of hydrochlorothiazide.
Question 5 of 5
A nurse is assessing a client who reports numbness and pain in his right palm, index finger, and middle finger. The client reports working with a keyboard most of the time while at work. The nurse suspects carpal tunnel syndrome. Which of the following tests should the nurse request that the client perform?
Correct Answer: B
Rationale: The correct answer is B: Phalen's test. Phalen's test is used to assess for carpal tunnel syndrome by having the client flex the wrists and press the backs of the hands together for 1 minute to compress the median nerve. This test reproduces symptoms in individuals with carpal tunnel syndrome due to increased pressure on the median nerve. Tinel's sign (
A) is used to assess for nerve compression, but it is not specific to carpal tunnel syndrome. Rinne's test (
C) is used to assess for hearing loss. Romberg test (
D) is used to assess for balance and proprioception issues.
Choices E, F, and G are not relevant to assessing carpal tunnel syndrome.