Questions 60

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ATI Advanced Med Surg Exam 3 Questions

Extract:


Question 1 of 5

A patient with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation (SpO2) of 78%. The patient is increasingly lethargic. Which intervention will the nurse anticipate?

Correct Answer: B

Rationale: Severe respiratory failure with low respiratory rate and SpO2 requires endotracheal intubation to ensure adequate ventilation and oxygenation.

Question 2 of 5

A nurse is caring for a client who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select all that apply.)

Correct Answer: B,D,E

Rationale: Daily verification of ventilator settings ensures safety, pantoprazole prevents stress ulcers, and elevating the head of the bed reduces ventilator-associated pneumonia risk.

Question 3 of 5

A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication that the client might be experiencing circulatory overload?

Correct Answer: C

Rationale: Dyspnea indicates pulmonary congestion from circulatory overload, a common complication of rapid blood transfusion.

Question 4 of 5

A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip?

Correct Answer: A

Rationale: Pacemaker spikes before each QRS complex indicate proper ventricular pacing, stimulating ventricular depolarization.

Question 5 of 5

The rapid response team (RRT) is caring for a client with asystole. Which nursing statement made to the client's family about the actions of the RRT is appropriate?

Correct Answer: D

Rationale: Asystole is not defibrillatable, so the RRT continues CPR, and this statement accurately informs the family.

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