ATI RN
RN ATI Adult Medsurg Proctored Exam 2023 With NGN Questions
Extract:
Question 1 of 5
A nurse is teaching a client who has a new prescription for phenytoin to treat a seizure disorder. Which of the following adverse effects should the nurse instruct the client to report immediately to the provider?
Correct Answer: C
Rationale: The correct answer is C: Skin rash. This is because phenytoin can cause severe and potentially life-threatening skin reactions like Stevens-Johnson syndrome or toxic epidermal necrolysis. These reactions can progress rapidly, so immediate medical attention is crucial. Drowsiness (
A) is a common side effect of phenytoin but not typically an emergency. Gingival hyperplasia (
B) and mild nausea (
D) are common side effects that do not require immediate reporting.
Question 2 of 5
A nurse is assessing a clients ECG strip and notes an irregular heart rate of 98/min with no clear P waves. Which of the following cardiac dysrhythmias should the nurse document?
Correct Answer: B
Rationale: The correct answer is B: Atrial fibrillation. In atrial fibrillation, the heart rate is irregular and fast (98/min), and there are no clear P waves on the ECG strip, which aligns with the findings in the scenario. Atrial fibrillation is characterized by chaotic electrical activity in the atria, leading to an irregular heart rate. Sinus bradycardia (
A) is characterized by a slow heart rate with normal P waves. Ventricular tachycardia (
C) is a fast heart rhythm originating in the ventricles with distinct QRS complexes. First-degree heart block (
D) is identified by a prolonged PR interval but should still have clear P waves. Other choices are not relevant. In this case, the absence of clear P waves and irregular heart rate point towards atrial fibrillation as the correct dysrhythmia to document.
Question 3 of 5
A nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions should the nurse implement to decrease the clients risk for ventilator-associated pneumonia (VAP)? (Select all that apply.)
Correct Answer: B, C, E
Rationale:
Correct Answer: B, C, E
Rationale:
- Monitoring for oral secretions every 2 hr helps prevent aspiration of secretions, reducing the risk of VAP.
- Providing oral care every 2 hr reduces the bacterial load in the mouth, decreasing the risk of VAP.
- Assessing the client daily for readiness of extubation allows for timely removal of the ventilator, reducing the duration of ventilation and lowering the risk of VAP.
Incorrect
Choices:
- Wearing a protective gown when suctioning the client's airway does not directly decrease the risk of VAP.
- Maintaining the client in a supine position may increase the risk of aspiration and VAP.
Question 4 of 5
A nurse is providing teaching about health promotion activities for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: B
Rationale:
Correct Answer: B
Rationale:
1. Checking blood sugar before exercise is crucial for individuals with type 1 diabetes to prevent hypoglycemia.
2. It allows the client to adjust their insulin dosage or carbohydrate intake based on their blood sugar level.
3. Monitoring blood sugar helps maintain safe levels during physical activity.
4. Other choices are incorrect as high-protein diet may not be necessary, avoiding all sugar is extreme, and insulin should be taken as prescribed, not based on symptoms.
Question 5 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.