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: Increase in blood pressure from 130/80 mm Hg to 180/100 mm Hg. Cushing's triad is a set of three classic signs indicating increased intracranial pressure (ICP). The triad includes hypertension (widening pulse pressure), bradycardia, and irregular respirations. In this case, an increase in blood pressure is consistent with the hypertension component of Cushing's triad. This occurs due to the body's compensatory mechanism to maintain perfusion to the brain in response to increased ICP.
Choices B, C, D, and E do not align with the classic signs of Cushing's triad. Bradycardia, not a decrease in heart rate, is typically seen in Cushing's triad. Rapid and shallow respirations are not part of the triad. Hypotension is not a characteristic finding in Cushing's triad.
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 effectively pump blood to the lungs for oxygenation, causing blood to back up into the systemic circulation. This leads to fluid retention, particularly in the lower extremities and abdomen, resulting in increased abdominal girth. Crackles in the lungs (
A) are indicative of left-sided heart failure due to pulmonary congestion. Pink frothy sputum (
C) is associated with pulmonary edema, a sign of left-sided heart failure. Hypertension (
D) is not typically associated with right-sided heart failure, as it is more commonly seen in conditions like systemic hypertension.
Question 3 of 5
A nurse is providing teaching to a client who has a new prescription for levothyroxine to treat hypothyroidism. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: B
Rationale:
Correct
Answer: B - If my heart starts racing
Rationale: This statement indicates an understanding of a potential side effect of levothyroxine, which is palpitations or rapid heart rate. It shows that the client is aware of the importance of monitoring for adverse reactions and seeking medical attention if necessary. This is crucial as it can indicate overmedication, which can be harmful.
Incorrect
Choices:
A: Taking levothyroxine with food can interfere with its absorption, reducing its effectiveness.
C: Adjusting the dosage is the healthcare provider's responsibility based on lab results, not the client's decision.
D: Stopping the medication abruptly can lead to a worsening of hypothyroidism symptoms.
E: Taking levothyroxine at night can interfere with sleep patterns and absorption.
Question 4 of 5
A nurse is assessing a client who is 24 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Maintain abduction of the affected extremity. After a total hip arthroplasty, maintaining abduction of the affected extremity helps prevent dislocation of the hip prosthesis. This position helps stabilize the hip joint and reduces the risk of complications. Option B (Position the client in high Fowler's position) is incorrect as it does not directly address the postoperative care specific to a total hip arthroplasty. Option C (Encourage the client to cross their legs at the ankles) is incorrect because crossing legs can create pressure on the hip joint and increase the risk of dislocation. Option D (Have the client bend forward at the waist while sitting) is incorrect as this could also increase the risk of hip dislocation.
Question 5 of 5
A nurse is providing teaching to a client who is scheduled for a bronchoscopy. Which of the following statements should the nurse include in the teaching?
Correct Answer: A
Rationale:
Correct
Answer: A
Rationale: The nurse should include the statement "You will not be able to eat or drink after the procedure until you are able to cough" because it is essential for the client's safety to prevent aspiration. After a bronchoscopy, the client may have an impaired gag reflex from the procedure, increasing the risk of choking.
Therefore, it is crucial to wait until the gag reflex returns before eating or drinking. This statement emphasizes the importance of airway protection post-procedure.
Summary:
B: Incorrect - Breathing during a bronchoscopy is usually done through the mouth.
C: Incorrect - Bronchoscopy is uncomfortable but not typically painful due to sedation.
D: Incorrect - Sedation is commonly used during bronchoscopy to ensure client comfort.
E: Incorrect - Bed rest after a bronchoscopy is not typically necessary unless complications arise.