ATI RN
ATI RN Adult Medical Surgical 2023 Questions Correct Answers Questions
Extract:
Question 1 of 5
A nurse is planning care for a client who has a seizure disorder. Which of the following equipment should the nurse place in the client's room?
Correct Answer: D
Rationale: The correct answer is D: Oral airway. During a seizure, a client may experience difficulty breathing due to their airway being obstructed. Placing an oral airway helps maintain a clear airway, ensuring adequate oxygenation. NG tube (
A) is not relevant to managing seizures.
Tongue blade (
B) can cause injury during a seizure. Wrist restraints (
C) are not appropriate and can increase the risk of injury.
Question 2 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 3 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 4 of 5
A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following medications should the nurse instruct the client to avoid? (Select all that apply)
Correct Answer: C, E
Rationale: The correct choices are C (Aspirin) and E (Naproxen) because they both increase the risk of bleeding when used with warfarin, an anticoagulant. Aspirin and Naproxen are nonsteroidal anti-inflammatory drugs (NSAIDs) that can further inhibit platelet function and prolong bleeding time, leading to potential complications. Ferrous sulfate (
A) is an iron supplement and does not directly interact with warfarin. Echinacea (
B) is an herbal supplement with minimal known interactions with warfarin. Dextromethorphan (
D) is a cough suppressant and does not impact warfarin's anticoagulant effects. In summary, the nurse should instruct the client to avoid Aspirin and Naproxen to prevent potential bleeding complications when taking warfarin.
Question 5 of 5
A nurse is caring for a client who has chronic venous insufficiency. Which of the following areas should the nurse assess for the presence of a venous ulcer?
Correct Answer: B
Rationale: The correct answer is B: Medial malleolus (ankle). Venous ulcers commonly occur in the lower legs, particularly around the medial malleolus due to poor circulation in chronic venous insufficiency. The pressure and pooling of blood in the veins can lead to tissue breakdown and ulcer formation in this area. Assessing the medial malleolus for the presence of a venous ulcer is crucial in managing the client's condition.
Incorrect
Choices:
A: Tip of the toes - Venous ulcers are less likely to occur in this area as it is more distal and less affected by venous insufficiency.
C: Ball of the foot - Venous ulcers are more commonly found in the lower legs rather than the ball of the foot.
D: Heel of the foot - While ulcers can develop on the heel, they are less likely to be venous ulcers in chronic venous insufficiency compared to the medial malleol