Questions 87

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ATI RN Adult Medical Surgical 2023 Questions

Extract:

Findings upon admission:
Vital Signs

Blood pressure 106/64 mm Hg

Heart rate 95/min

Respiratory rate 20/min

Temperature 37.8° C (100° F)

Oxygen saturation 95% on O, at 3 L/min via nasal cannula


Question 1 of 5

A nurse is caring for an older adult client who was admitted with a urinary tract infection. The nurse is assessing the client 12 hr later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition.

Options Unrelated to diagnosis Indication of potential improvement Indication of potential worsening condition
Disoriented to person, place, and time
Oxygen saturation 96% at 2 L/min via nasal cannula
Hct 45%
Butterfly rash
Blood pressure 100/50 mm Hg

Correct Answer:

Rationale: Disorientation and low BP worsen UTI; improved O2 is a sign of improvement; Hct is normal; rash is unrelated.

Extract:

History and Physical
History
Client reports after eating breakfast this morning at 0630 that they began feeling tightness in chest that radiates to left arm.


Question 2 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,D,E

Rationale: Chest tightness radiating to the arm suggests an acute coronary event, requiring catheterization, heparin, metoprolol, and NPO status.

Extract:


Question 3 of 5

A nurse is caring for a client after total hip replacement surgery. Which of the following actions should the nurse take?

Correct Answer: A

Rationale: An elevated toilet seat prevents hip flexion beyond 90 degrees, reducing dislocation risk.

Question 4 of 5

A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration?

Correct Answer: C

Rationale: Decreased blood pressure is a sign of dehydration due to fluid loss.

Question 5 of 5

A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft?

Correct Answer: D

Rationale: A palpable thrill indicates adequate blood flow through the arteriovenous graft.

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