ATI RN
ATI RN Adult Medical Surgical 2023 III Questions
Extract:
Question 1 of 5
A nurse is instructing a client who has left-sided hemiparesis about the use of a quad cane. Which of the following actions by the client indicates an understanding of the teaching?
Correct Answer: B
Rationale: Maintaining two points of support (cane and one foot) ensures stability when using a quad cane.
Question 2 of 5
A nurse is providing teaching for the family of a client who has Alzheimer's disease. Which of the following statements should the nurse include?
Correct Answer: A
Rationale: Structured activities help maintain routine and reduce confusion in clients with Alzheimer's disease.
Extract:
Nurses' Notes
Day 1:
1000:
Client is alert to person, place, and time. Client is short of breath and leans forward to breathe easier. Lung sounds are diminished in bilateral bases with occasional wheezes. Nonproductive cough. Heart rate is regular. +2 pulses in all extremities.
1500:
Client is tachypneic, cough is productive, and mucous is yellow in color. Wheezes and crackles heard upon auscultation. Heart rate is regular. +2 pulses in all extremities. Client is oriented to person, place and time. Client is restless. Pupils are reactive to light. Client is diaphoretic with cyanotic mucous membranes
Vital Signs
1000:
Temperature: 37.1°C (98.8°F)
Heart Rate: 100/min
Respiratory Rate: 22/min (irregular)
Blood Pressure: 164/80 mm Hg
Oxygen Saturation: 92% on room air
1500:
Temperature: 37.3°C (100.3°F)
Heart Rate: 110/min
Respiratory Rate: 26/min (irregular)
Blood Pressure: 110/58 mm Hg
Oxygen Saturation: 87% on room air
Question 3 of 5
A nurse is caring for a client who has COPD. Select the findings below that require immediate follow-up.
Correct Answer: B,C,E,F
Rationale: Restlessness, tachypnea, yellow mucous, and wheezes/crackles indicate worsening COPD requiring intervention.
Extract:
Question 4 of 5
A nurse in the emergency department is evaluating a young adult client for bacterial meningitis. Which of the following actions should the nurse take as part of the focused assessment?
Correct Answer: A
Rationale: Nuchal rigidity is a hallmark sign of bacterial meningitis, assessed by checking neck stiffness.
Question 5 of 5
A nurse is caring for a client immediately following a lumbar puncture. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Lying flat post-lumbar puncture reduces the risk of spinal headache due to cerebrospinal fluid leakage.