ATI RN
ATI RN Med Surg Custom Exam 2 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who reports an area of redness, warmth, tenderness, and pain in the right calf. The nurse anticipates which of the following orders when notifying the provider of this finding?
Correct Answer: C
Rationale: Venous duplex ultrasound is the most common test used to diagnose DVT. It uses sound waves to create pictures of the blood flowing through the veins in the leg.
Question 2 of 5
While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: The nurse should first discontinue the existing IV line. This is because the symptoms indicate that the client might have developed phlebitis, an inflammation of the vein, which requires immediate discontinuation of the IV line.
Question 3 of 5
A nurse is caring for a client and identifies an infiltration at the IV catheter site. Identify the order the nurse should perform the following actions.
Correct Answer: C,A,E,B,D
Rationale: Here's the correct order of actions for managing an IV infiltration: C. Stop the infusion. (This is the priority action to prevent further infiltration.) A. Remove the IV catheter. (Once the infusion is stopped, the source of the infiltration needs to be removed.) E. Elevate the extremity. (This helps reduce swelling.) B. Apply warm or cold compresses. (This helps reduce discomfort and swelling. Warm compresses are generally used for non-vesicant solutions, while cold compresses are used for vesicant solutions, or as ordered. The type of fluid infiltrated is important to know.) D. Apply a sterile dressing. (This protects the insertion site and prevents infection.)
Question 4 of 5
A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8° C (98.2° F). Which of the following actions should the nurse perform?
Correct Answer: A
Rationale: Completing a neurological check is the correct action. The client's sudden confusion and drowsiness could indicate a neurological issue, such as a stroke.
Question 5 of 5
A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Placing the client on his side, specifically the recovery position, helps keep the airway clear and prevents aspiration.