ATI RN
RN ATI Adult Medsurg Proctored Exam 2023 With NGN Questions
Extract:
Question 1 of 5
A nurse is providing teaching for a client who has neutropenia and is receiving chemotherapy. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.)
Correct Answer: A, C
Rationale: The correct answers are A and C. Neutropenia and chemotherapy increase the risk of infection. Avoiding crowds (
A) reduces exposure to infectious agents. Taking temperature daily (
C) helps detect early signs of infection. Washing toothbrush weekly (
B) is important but daily is recommended. Eating fresh fruits and vegetables (
D) is beneficial but may pose infection risk.
Question 2 of 5
A nurse is assessing a client who has a chest tube connected to a closed water-seal drainage system. Which of the following findings should the nurse report to the provider?
Correct Answer: A
Rationale: The correct answer is A: Constant bubbling in the water seal chamber. This finding indicates an air leak in the system, which can compromise the client's respiratory status. The continuous bubbling signifies that air is escaping through the chest tube rather than being properly drained. The nurse should report this to the provider immediately for further evaluation and intervention to prevent pneumothorax or other complications.
The other choices (B, C,
D) are incorrect because intermittent bubbling in the suction chamber is expected as it indicates proper functioning of the system. Clear drainage of 50 mL over 8 hours is within normal limits and does not pose an immediate threat to the client. Mild pain at the insertion site is also a common finding after chest tube insertion and does not require urgent intervention unless it worsens or is accompanied by other concerning symptoms.
Question 3 of 5
A nurse is caring for a client who has a small bowel obstruction and an NG tube in place. Which of the following actions should the nurse take?
Correct Answer: A
Rationale:
Correct
Answer: A: Maintain low intermittent suction.
Rationale: Maintaining low intermittent suction helps to decompress the bowel, reducing the risk of further obstruction. Suction also helps to remove excess fluid and gas from the digestive system, providing relief to the client. It is essential to prevent excessive suction, as it can cause damage to the bowel and worsen the obstruction.
Summary of other choices:
B: Clamping the NG tube every 2 hours is not recommended as it can lead to a buildup of fluid and gas in the bowel, potentially worsening the obstruction.
C: Removing the NG tube immediately is contraindicated as it is necessary for decompression and monitoring of bowel function.
D: Encouraging high-fiber foods is inappropriate in the case of a small bowel obstruction as it can further obstruct the bowel.
Question 4 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 Cushings 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 classic sign of increased intracranial pressure (ICP), seen in traumatic brain injury. It consists of hypertension (elevated blood pressure), bradycardia (not tachycardia), and irregular respirations (not rapid shallow respirations). The increase in blood pressure is due to the body's attempt to maintain cerebral perfusion in response to the increased ICP. The other choices are incorrect because they do not align with the classic presentation of Cushing's triad in traumatic brain injury.
Question 5 of 5
A nurse is preparing to administer potassium chloride 10 mEq IV over 1 hr to a client. Available is potassium chloride 10 mEq in 100 mL of 0.9% sodium chloride. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number.)
Correct Answer: C
Rationale:
To calculate the infusion rate, we need to use the formula: (Desired dose ÷ Volume) x 60 minutes. In this case, the desired dose is 10 mEq over 1 hour, and the volume is 100 mL.
So, (10 ÷ 100) x 60 = 6 mL/hr.
Therefore, the nurse should set the infusion pump to deliver 100 mL/hr. This ensures the correct administration of potassium chloride over the specified time frame.
Choice A (50 mL/hr) and B (75 mL/hr) are incorrect as they would result in the underdosing of potassium chloride.
Choice D (125 mL/hr) is incorrect as it would result in the overdosing of potassium chloride. The correct answer, C (100 mL/hr), ensures the proper administration of the medication within the specified parameters.