ATI RN
ATI RN Adult Medical Surgical 2023 V Questions
Extract:
Question 1 of 5
A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse plan to include?
Correct Answer: C
Rationale: A low bed height reduces fall risk, a priority for dementia clients with impaired judgment.
Question 2 of 5
A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: Lowering the client to the floor prevents injury from falling, the priority during a seizure.
Extract:
History and Physical
1000:
Client reports after eating breakfast this morning at 0630 that they began feeling tightness in chest that radiates to left arm. History:
Hyperlipidemia, hypertension, type 2 diabetes mellitus. Non-smoker. Denies use of alcohol or recreational drug use.
Nurses' Notes
1000:
Client reports tightness in chest that radiates to left arm. States pain as 7 on a scale of 0 to 10. Started to feel nauseous after breakfast. Client states, "I had scrambled eggs and bacon like I do every morning." Client is diaphoretic and short of breath. Heart rate irregular and tachycardic. Alert and oriented to person, place, and time. Lungs clear to auscultation in all lobes. Bowel sounds are present in all 4 quadrants. +1 pedal pulses. Skin is cool to touch. Capillary refill less than 2 seconds.
Vital Signs
1000:
• Temperature 37.1° C (98.8° F)
• Heart rate 110/min and irregular
• Respiratory rate 24/min
• Blood pressure 164/80 mm Hg
• Oxygen saturation 93% on room air
Diagnostic Results
1000:
• Myoglobin 100 mcg/L (less than 90 mcg/L)
• Creatine kinase 180 units/L (55 to 170 units/L)
• Troponin T 0.40 ng/mL (less than 0.1 ng/mL)
• Troponin 10.35 ng/mL (less than 0.03 ng/mL)
• Cholesterol 244 mg/dL (less than 200 mg/dL)
• Triglycerides 180 mg/dL (40 to 160 mg/dL)
• LDL cholesterol 148 mg/dL (less than 130 mg/dL)
• HDL cholesterol 42 mg/dL (greater than 45 mg/dL)
• C-reactive protein 2 mg/mL (less than 1.0 mg/mL)
• Blood glucose 103 mg/dL (74 to 106 mg/dL)
12-lead electrocardiogram: tachycardia with ST segment elevation and T wave changes
Chest x-ray: lungs are clear in all lobes
Provider prescriptions
1020:
• Nitroglycerin 0.5 mg SL may repeat every 5 min up to 3 doses as needed for chest pain
• Aspirin 160 mg PO daily
• Morphine 6 mg IV bolus every 3 hr PRN pain
• Metoprolol 25 mg PO every 6 hr x 48 hr, then metoprolol 100 mg PO twice daily
• Initiate peripheral IV site
• 0.9% sodium chloride 50 mL/hr by continuous IV infusion
• Oxygen at 2 L/min via nasal cannula if oxygen saturation is less than 90%
• Schedule stat echocardiogram
• 2 g sodium diet
Question 3 of 5
A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Select the findings below that would indicate that the client has a potential problem.
Correct Answer: A,C,E
Rationale: Pain, diaphoresis, shortness of breath, and cool skin suggest acute coronary syndrome.
Extract:
Question 4 of 5
A nurse is caring for a client in the ICU. The client's ECG monitor tracing reveals sinus bradycardia and ST segment elevation. The client reports shortness of breath and feeling dizzy and faint. Which of the following medications should the nurse administer?
Correct Answer: C
Rationale: Atropine treats symptomatic bradycardia, addressing the low heart rate and associated symptoms like dizziness and shortness of breath.
Question 5 of 5
A nurse is caring for a client who has a sealed radiation implant. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Limiting visitor time reduces radiation exposure, a key safety measure for sealed implants.