ATI RN
RN ATI Adult Medsurg Proctored Exam 2023 With NGN Questions
Extract:
Question 1 of 5
A nurse is teaching a client about self-management of their halo fixator device. Which of the following information should the nurse include in the teaching?
Correct Answer: A
Rationale: The correct answer is A: Place a small pillow under the head while lying supine. This is important to prevent hyperextension of the neck while lying down, ensuring proper alignment and comfort. Removing the vest (
B) compromises stability. Applying lotion (
C) can cause skin breakdown. Adjusting screws (
D) without proper training can lead to complications.
Question 2 of 5
A nurse is planning preventative strategies for a client who is at risk for pressure injuries. Which of the following actions should the nurse include in the plan?
Correct Answer: A
Rationale: The correct answer is A: Apply moisturizer to damp skin after bathing. Moisturizing helps maintain skin integrity and hydration, reducing the risk of pressure injuries. When skin is damp, it is more receptive to hydration, which can prevent dryness and breakdown. Applying moisturizer also helps to maintain the skin's natural barrier function. Massaging bony prominences (choice
B) can actually increase the risk of pressure injuries by causing friction and shearing forces. Using cornstarch powder (choice
C) can lead to moisture buildup and increase the risk of skin breakdown. Positioning the client at a 90-degree angle in bed (choice
D) is not a recommended preventive strategy for pressure injuries.
Question 3 of 5
A nurse is caring for a client who has multiple leg fractures and is 24 hr postoperative following placement of skeletal traction. Which of the following actions should the nurse take?
Correct Answer: A
Rationale:
Correct Answer: A. Inspect the pin sites at least every 8 hr.
Rationale:
1. Inspecting pin sites regularly is crucial to monitor for signs of infection or other complications.
2. Postoperative clients with skeletal traction are at high risk for pin site infections.
3. Regular inspection allows early detection and intervention to prevent complications.
4. Waiting longer than every 8 hours may lead to delayed identification of issues.
Summary:
B. Applying direct pressure is contraindicated as it can cause harm.
C. Removing traction weights without medical order can lead to complications.
D. Encouraging vigorous movement is inappropriate and can cause harm.
Question 4 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.
Question 5 of 5
A nurse is assessing a client who has a history of type 2 diabetes mellitus. The nurse should identify which of the following findings as an indication of a microvascular complication?
Correct Answer: C
Rationale: The correct answer is C: Retinopathy. In type 2 diabetes mellitus, microvascular complications involve damage to small blood vessels. Retinopathy specifically affects the blood vessels in the retina, leading to vision problems. Peripheral neuropathy (
A) is a macrovascular complication affecting nerves. Hypertension (
B) is a common comorbidity in diabetes but not a direct microvascular complication. Stroke (
D) is a macrovascular complication involving larger blood vessels in the brain.
Therefore, the presence of retinopathy is a clear indication of a microvascular complication in a client with type 2 diabetes mellitus.