ATI RN
ATI Medsurg Proctored Final Exam Questions
Extract:
Question 1 of 5
A nurse is teaching a newly licensed nurse about gynecological examination. Which of the following information should the nurse include in the teaching?
Correct Answer: A
Rationale:
Correct Answer: A
Rationale: The urethral orifice is located between the clitoris and vaginal opening, so separating the labia minora is necessary to assess it. This step ensures proper assessment of the urinary system and helps detect any abnormalities.
Summary of Incorrect
Choices:
B: Palpating the cervix for size is not a standard part of a gynecological examination; it may cause discomfort and is unnecessary unless indicated for specific medical reasons.
C: Inspecting the vagina without a speculum is not recommended as it may not provide a clear view of the vaginal walls and cervix, potentially missing important findings.
D: Massaging the clitoris is not a part of a gynecological examination and is inappropriate; it may be uncomfortable for the patient and is not relevant to the assessment.
Question 2 of 5
A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction?
Correct Answer: A
Rationale: The correct answer is A: Perform a 12-lead ECG. This is because an ECG is the most reliable and direct way to assess for myocardial infarction by identifying characteristic changes in the heart's electrical activity. Nitroglycerin (
B) is used to relieve chest pain but should not be administered before confirming the diagnosis. Placing the client in a prone position (
C) is not appropriate for assessing chest pain. Assessing blood pressure (
D) is important but not the initial priority when suspecting myocardial infarction.
Question 3 of 5
A nurse is caring for a client who has a postoperative ileus and an NG tube that has drained 2,500 mL in the past 6 hr. Which of the following electrolyte imbalances should the nurse monitor the client for?
Correct Answer: A
Rationale: The correct answer is A: Decreased potassium level. Postoperative ileus can lead to gastrointestinal fluid losses, causing a decrease in potassium levels due to excessive drainage through the NG tube. Potassium is an important electrolyte for maintaining normal muscle function, including the heart. Monitoring potassium levels is essential to prevent complications such as cardiac arrhythmias.
Incorrect choices:
B: Increased sodium level - Unlikely in this scenario as excessive drainage would lead to fluid and electrolyte loss.
C: Increased calcium level - Unrelated to postoperative ileus and NG tube drainage.
D: Decreased magnesium level - Possible but not as critical as monitoring potassium levels in this situation.
Question 4 of 5
A nurse is preparing to administer potassium chloride (KCL) to a client who is receiving diuretic therapy. The nurse reviews the client's serum potassium level results and discovers the client's potassium level is 3.2 mEq/L. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Give the ordered KCL as prescribed. The nurse should administer potassium chloride as prescribed because the client's potassium level of 3.2 mEq/L is within the normal range (3.5-5.0 mEq/L). Potassium chloride is indicated for clients with hypokalemia (low potassium levels), and the client's level falls within the normal range, so administering the ordered KCL is appropriate. Holding the KCL is unnecessary since the potassium level is not critically low. Administering potassium via IV push is not indicated as the client's potassium level is not critically low. Checking the client's potassium level again in 1 hour is unnecessary as the level is already within the normal range.
Question 5 of 5
A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Excessive thrombosis and bleeding. In DIC, there is a widespread activation of the clotting cascade leading to formation of microthrombi, causing excessive clotting. However, as the clotting factors are depleted, bleeding can occur. This results in a paradoxical situation of both thrombosis and bleeding. B is incorrect as clotting of mucous membranes is not specific to DIC. C is incorrect as platelet count is usually decreased in DIC due to consumption. D is incorrect as excessive red blood cell count is not a characteristic of DIC.