ATI RN
ATI Med Surg Nurs 300 Day Exam 4 Questions
Extract:
Question 1 of 5
A patient is prescribed 500 ml of Normal Saline to be infused over 90 minutes. The drop factor on the tubing is 10 gtt/mL. At what rate should the nurse regulate the IV (gtt/min)? (Round to the nearest whole number)
Correct Answer: A
Rationale: The infusion rate is calculated as 500 mL / 90 min = 5.5556 mL/min. With a drop factor of 10 gtt/mL, the drip rate is 5.5556 mL/min x 10 gtt/mL = 55.556 gtt/min, rounded to 56 gtt/min.
Question 2 of 5
The nurse is caring for a client who had a central venous catheter placed in the right subclavian vein. Approximately 30 minutes after placement the client has become increasingly restless, has jugular vein distention, and a heart rate of 120 beats per minute. The nurse would assess for which possible complication?
Correct Answer: B
Rationale: Restlessness, jugular vein distention, and tachycardia post-subclavian catheter placement suggest pneumothorax, a complication from lung puncture during insertion.
Question 3 of 5
The nurse is caring for a client three hours after percutaneous coronary intervention (PCI) with stent placement. The client now complains of 5/10 chest pain. The client is visibly diaphoretic and anxious. The ECG shows ST segment elevations. The vital signs are as follows: BP: 156/82, HR: 110, RR: 20, T: 98.6, and Sp02: 94% on 2L nasal canula. The nurse anticipates which intervention in this situation?
Correct Answer: D
Rationale: Chest pain with ST elevations post-PCI suggests reocclusion, requiring repeat PCI to restore coronary blood flow.
Question 4 of 5
The nurse monitors the client in the immediate hours following an anterior-lateral wall myocardial infarction for the development of:
Correct Answer: B
Rationale: Ventricular dysrhythmias are a common and life-threatening complication in the immediate hours following an anterior-lateral wall myocardial infarction due to electrical disturbances caused by myocardial injury.
Question 5 of 5
The nurse is caring for a client whose arterial blood gas reveals fully compensated metabolic acidosis. Which results are consistent with this finding?
Correct Answer: A
Rationale: Normal pH (7.36), low HCO3 (16 mEq/L), and low PaCO2 (27 mmHg) indicate fully compensated metabolic acidosis with respiratory compensation.