ATI RN
ATI RN Adult Medical Surgical 2023 Questions Correct Answers Questions
Extract:
Question 1 of 5
A nurse is monitoring a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a manifestation of Cushing's triad?
Correct Answer: A
Rationale: The correct answer is A because Cushing's triad consists of hypertension, bradycardia, and irregular respirations. In a client with a traumatic brain injury, increased intracranial pressure can lead to Cushing's triad due to brainstem compression. Option A reflects an increase in blood pressure, which is a key component of Cushing's triad.
Choices B, C, and D do not align with the expected findings of Cushing's triad.
Choice B indicates a decrease in heart rate, which is contrary to the bradycardia seen in Cushing's triad.
Choice C mentions rapid respirations, whereas irregular or shallow respirations are more characteristic.
Choice E mentions hypotension, which is not part of Cushing's triad.
Therefore, option A is the correct choice as it aligns with the manifestation of hypertension in Cushing's triad.
Question 2 of 5
A nurse is teaching a client who has left-sided weakness how to use a quad cane. Which of the following client actions indicates an understanding of the teaching?
Correct Answer: B
Rationale: The correct answer is B. Advancing the weaker leg forward to the cane provides stability and support, helping distribute weight evenly and preventing falls. This step is crucial in using a quad cane effectively. Moving the cane too far ahead (
A) could cause imbalance. Taking a step with the stronger leg first (
C) would not provide the needed support for the weaker side. Holding the cane with the same side as the weakness (
D) may not provide the necessary support. It is essential to prioritize stability and weight distribution, making option B the correct choice.
Question 3 of 5
A nurse is preparing to obtain a guaiac smear sample from a client for fecal occult blood testing. Which of the following actions should the nurse plan to take?
Correct Answer: D
Rationale: The correct answer is D: Discard samples that contain urine. This is crucial because urine can interfere with the accuracy of the fecal occult blood test results, leading to false positives. By discarding samples that contain urine, the nurse ensures the reliability of the test.
A: Taking the sample from the outer edge of formed stool is not necessary for a guaiac smear sample.
B: Wearing sterile gloves is important for infection control but not specifically for collecting a guaiac smear sample.
C: Collecting three samples from a single bowel movement is not standard practice for fecal occult blood testing and may not be necessary.
E, F, G: No further options provided.
Question 4 of 5
A nurse is providing dietary instructions to a client who has cardiovascular disease. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: C
Rationale: The correct answer is C: "I will use canola oil when making salad dressing." Canola oil is a healthier choice than other oils, as it is low in saturated fats and high in monounsaturated fats, which are beneficial for cardiovascular health. Using canola oil in salad dressing can help decrease the intake of unhealthy fats.
Choice A is incorrect because limiting meat portions alone may not address overall dietary fat intake.
Choice B is incorrect as canned vegetables may contain added sodium, which is not ideal for cardiovascular health.
Choice D is incorrect as whole milk is high in saturated fats, not recommended for cardiovascular disease.
Question 5 of 5
A nurse is analyzing the ABG results of a client who is in respiratory acidosis. Which of the following mechanisms should the nurse identify as responsible for this acid-base imbalance?
Correct Answer: A
Rationale: The correct answer is A: Retention of carbon dioxide. In respiratory acidosis, there is an accumulation of carbon dioxide in the bloodstream due to inadequate ventilation. This leads to increased levels of carbonic acid, causing the blood pH to decrease. The nurse should identify this mechanism as responsible for the acid-base imbalance.
Loss of bicarbonate (
B) would lead to metabolic acidosis, not respiratory acidosis. Excessive vomiting (
C) would result in metabolic alkalosis. Hyperventilation (
D) would actually help correct respiratory acidosis by blowing off excess carbon dioxide.