ATI RN
ATI Advanced Med Surg Final Exam 0924 Questions
Extract:
Question 1 of 5
A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Performing pre-oxygenation prior to suctioning can help prevent hypoxia and subsequent cardiac arrhythmias caused by the suctioning procedure.
Question 2 of 5
A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Homonymous hemianopsia involves loss of vision in one half of the visual field; reminding the client to look to the left side of the tray helps them find food in their impaired visual field.
Question 3 of 5
A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status?
Correct Answer: C
Rationale: Instructing the client to wiggle his toes assesses motor function and circulation to the distal extremities, which are crucial for neurovascular status.
Question 4 of 5
A nurse on a telemetry unit is caring for a client who has premature ventricular contractions (PVCs). While sitting in a chair, the client reports feeling lightheaded. If the client is having PVCs, which of the following findings should the nurse expect when auscultating the client's apical pulse?
Correct Answer: A
Rationale: Irregular pulsations are expected with PVCs because they cause occasional early beats that disrupt the regular rhythm of the pulse.
Extract:
Medical History
Day 1:
Client has a history of emphysema and reports smoking 21 packs of cigarettes per year.
Vital Signs
Day 1:
Temperature 37.6° C (99.7° F)
Blood pressure 114/56 mm Hg
Heart rate 78/min
Respiratory rate 20/min
Pulse oximetry 93% on room air
Day 2:
1000
Temperature 36.9° C (98.4° F)
Blood pressure 88/56 mm Hg
Heart rate 118/min
Respiratory rate 32/min
Pulse oximetry 85% on room air
Diagnostic Results
Day 1:
Chest x-ray shows lung hyperinflation.
Day 2
1000:
Chest x-ray shows right upper lobe pneumothorax.
Nurses' Notes
Day 2:
0800:
Voided 350 mL of clear yellow urine in a bedpan.
1000:
Client reports sudden, sharp, right upper chest pain.
Client appears anxious and states pain increases with deep breathing.
Respirations labored with use of accessory muscles noted.
Crepitus palpated on right upper chest.
Trachea midline, breath sounds decreased in right upper lobe.
Question 5 of 5
For each potential nursing action, click to specify if the action is essential, non-essential, or contraindicated for the client.
| Action | essential | non-essential | contraindicated |
|---|---|---|---|
| Administer an analgesic | |||
| Initiate a weight-based continuous heparin infusion | |||
| Initiate supplemental oxygen | |||
| Prepare client for a chest tube insertion | |||
| Insert an indwelling urinary catheter |
Correct Answer: A,C,D
Rationale: Administer an analgesic is essential for pain management. Initiate supplemental oxygen is essential due to low pulse oximetry. Prepare client for a chest tube insertion is essential to treat the pneumothorax.