ATI RN
ATI Medsurg Proctored Final Exam Questions
Extract:
Question 1 of 5
A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency?
Correct Answer: B
Rationale: The correct answer is B: Pallor and numbness distal to the fistula site. This is indicative of venous insufficiency in a client with an arteriovenous fistula. Venous insufficiency occurs when there is inadequate venous return to the heart, leading to decreased blood flow and oxygen delivery to the tissues. Pallor and numbness are signs of decreased blood flow, which can occur when the fistula is not functioning properly. Cold and numbness (choice
A) may indicate arterial insufficiency, not venous. Redness and warmth (choice
C) are signs of inflammation, not venous insufficiency. Pain in the fistula site (choice
D) may be due to other reasons like infection or nerve compression, not necessarily venous insufficiency.
Question 2 of 5
A nurse is reviewing laboratory values for a client who has systemic lupus erythematosus (SLE). Which of the following values should give the nurse the best indication of the client's renal function?
Correct Answer: A
Rationale: The correct answer is A: Serum creatinine. Creatinine is a waste product produced by muscles and filtered out by the kidneys. In clients with SLE, renal involvement is common. Elevated serum creatinine levels indicate impaired renal function, as the kidneys are not effectively filtering out waste products. Monitoring serum creatinine levels helps assess renal function and detect kidney damage early.
Choices B, C, D, and E are incorrect as they do not directly reflect renal function. Serum potassium levels (
B) are more indicative of electrolyte balance, white blood cell count (
C) indicates immune response, and hemoglobin level (
D) reflects oxygen-carrying capacity.
Question 3 of 5
A nurse is reviewing the laboratory values of a client who had a myocardial infarction 3 hr ago. The nurse should expect which of the following laboratory values to be elevated?
Correct Answer: C
Rationale: The correct answer is C: Troponin I. Troponin I is a specific marker for myocardial damage. After a myocardial infarction, the damaged heart muscle releases troponin I into the bloodstream, leading to elevated levels. This helps in diagnosing and monitoring the extent of myocardial damage.
A: Serum sodium levels are not typically affected by a myocardial infarction.
B: Serum glucose levels may be elevated due to stress response but are not specific to myocardial infarction.
D: White blood cell count may be elevated in response to inflammation caused by myocardial infarction, but it is not as specific as troponin I.
Question 4 of 5
A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency?
Correct Answer: A
Rationale: The correct answer is A: Cold and numbness distal to the fistula site. This is indicative of venous insufficiency, which can occur when the arteriovenous fistula is not functioning properly. When there is inadequate blood flow through the fistula, it can result in reduced circulation to the distal part of the arm, leading to coldness and numbness. Swelling around the fistula (choice
B) is more commonly associated with infection or inadequate drainage. Bleeding from the fistula (choice
C) is a potential complication but not a typical manifestation of venous insufficiency. Pain at the site of the fistula (choice
D) may indicate infection or clotting issues rather than venous insufficiency.
Question 5 of 5
A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?
Correct Answer: A
Rationale: The correct answer is A: Encourage the use of an incentive spirometer. This intervention helps prevent pulmonary complications postoperatively by promoting deep breathing, improving lung expansion, and preventing atelectasis. Incentive spirometry helps the client maintain lung function and prevent respiratory complications such as pneumonia. Administering oxygen therapy (
B) is important but not as effective in preventing complications as using an incentive spirometer. Early ambulation (
C) is beneficial for circulation but does not directly prevent pulmonary complications. Monitoring for chest pain (
D) is essential for assessing cardiac issues but does not specifically address pulmonary complications.