ATI RN
RN ATI Adult Medsurg Proctored Exam 2023 With NGN Questions
Extract:
Question 1 of 5
A nurse is monitoring a client following a lumbar laminectomy. The client has a drain and indwelling urinary catheter. The nurse should identify which of the following findings as an indication of a complication of the surgery?
Correct Answer: C
Rationale: The correct answer is C: Clear drainage on the dressings. Clear drainage may indicate a cerebrospinal fluid leak, which is a serious complication following a lumbar laminectomy. Cerebrospinal fluid is a clear fluid that surrounds the brain and spinal cord, and its leakage can lead to infection and other complications. Red-tinged drainage (choice
A) may be expected initially due to surgical trauma. Cloudy urine in the catheter (choice
B) is more likely related to urinary tract infection. Mild back pain at the surgical site (choice
D) is common after this surgery and does not necessarily indicate a complication.
Question 2 of 5
A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse identify as a manifestation of right-sided heart failure?
Correct Answer: B
Rationale: The correct answer is B: Increased abdominal girth. In right-sided heart failure, the heart is unable to efficiently pump blood to the lungs for oxygenation, leading to fluid backup in the systemic circulation. This results in fluid retention, particularly in the abdomen, causing increased abdominal girth. Crackles in the lungs (choice
A) are indicative of left-sided heart failure. Pink frothy sputum (choice
C) is a sign of pulmonary edema, which is a manifestation of left-sided heart failure. Hypertension (choice
D) is not typically associated with right-sided heart failure.
Question 3 of 5
A nurse is caring for a client who recently assumed the role of caregiver for their aging parents who have chronic illnesses. The nurse should identify that which of the following statements by the client indicates acceptance of the role change?
Correct Answer: B
Rationale: The correct answer is B. Changing the floor plan of the home to accommodate the father's wheelchair demonstrates acceptance of the caregiving role. This action shows that the client is willing to make necessary adjustments for their parents' needs, indicating a commitment to the role change.
A: Feeling overwhelmed and unsure indicates resistance to the role change.
C: Wishing for siblings' help suggests a desire to share responsibilities, not necessarily acceptance.
D: Feeling resentful points towards negative emotions, which do not align with acceptance.
Question 4 of 5
A nurse is caring for a client who is receiving vancomycin intermittent IV bolus therapy for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following findings is an indication to the nurse that the client is experiencing an adverse effect of the medication?
Correct Answer: B
Rationale: The correct answer is B: The client is becoming flushed. Flushing is a common adverse effect of vancomycin, indicating a possible allergic reaction or infusion reaction. Flushing can be a sign of red man syndrome, a severe reaction to vancomycin. The nurse should monitor closely and report this finding to the healthcare provider.
Incorrect Answer
Rationale:
A: The client reports ringing in the ears - this is a potential adverse effect of vancomycin, but not as critical as flushing.
C: The client reports increased thirst - this is not typically associated with vancomycin adverse effects.
D: The client has a decreased urine output - this may indicate nephrotoxicity, a known side effect of vancomycin, but flushing is more indicative of an immediate adverse reaction.
Question 5 of 5
A nurse is caring for a male client who has a new prescription for cyclosporine following a kidney transplant. Which of the following findings should the nurse identify as an adverse effect of this therapy?
Correct Answer: A
Rationale: The correct answer is A: BUN 24 mg/dL. Cyclosporine, an immunosuppressant medication, can cause nephrotoxicity as an adverse effect. An elevated BUN level indicates impaired kidney function, which can be a consequence of cyclosporine therapy. Blood glucose level (choice
B) and platelet count (choice
C) are not typically affected by cyclosporine. Hemoglobin level (choice E) is not directly related to cyclosporine therapy.
Therefore, the nurse should be vigilant for signs of nephrotoxicity by monitoring the client's BUN level.