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 admitting a client who reports tightness in their chest that radiates to left arm. Which of the following findings require immediate follow-up?
Correct Answer: B
Rationale: The correct answer is B: Heart rate 110/min and irregular. This finding suggests cardiac distress or arrhythmia, which could indicate a heart attack. Immediate follow-up is necessary to assess the client's cardiac status and intervene promptly.
Incorrect choices:
A: Temperature within normal range.
C: Respiratory rate within normal range.
D: Blood pressure slightly elevated but not an immediate concern.
E: Oxygen saturation slightly low but not critically low.
Question 3 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.
Question 4 of 5
A nurse is monitoring an older adult client who has an exacerbation of chronic lymphocytic leukemi The nurse notes petechiae on the client's skin. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Institute bleeding precautions. Petechiae are tiny red or purple spots on the skin caused by bleeding under the skin. In chronic lymphocytic leukemia, the client's platelet count may be low, leading to an increased risk of bleeding. By instituting bleeding precautions, the nurse can help prevent injuries that could result in further bleeding. Determining the client's blood type (
A) is not necessary in this situation. Avoiding IV pain medication (
B) is not directly related to managing petechiae. Implementing airborne precautions (
D) is not relevant to the client's presentation with petechiae.
Question 5 of 5
A nurse is caring for a client who is experiencing an acute asthma attack. Which of the following should the nurse identify as a contributing factor to the client's manifestations?
Correct Answer: D
Rationale: The correct answer is D: Inability to exhale retained carbon dioxide. During an acute asthma attack, there is airway obstruction, leading to air trapping and difficulty exhaling. This causes retention of carbon dioxide, leading to respiratory acidosis. This acidosis can further worsen the bronchoconstriction and airway inflammation in asthma.
Choices A, B, and C do not directly contribute to the manifestations of an acute asthma attack. Suppressed bronchiolar inflammatory response (
A) and decreased responsiveness of airways to allergens (
B) would not cause the acute symptoms seen in an asthma attack. Acute loss of alveolar elasticity (
C) is not a primary contributing factor to the acute manifestations of asthma.