ATI RN
ATI n269 Med Surg Comprehensive Exam Questions
Extract:
Nurses' notes
Client admitted with chest pain. Client is diaphoretic and short of breath. Client states. "Pain started when I began raking leaves in my yard. Pain "radiates to left arm and is a sharp pain." Cardiac enzymes indicate client is experiencing myocardial infarction. Provider notified and to prepare client for cardiac catheterization Immediately
A nurse is admitting a client who reports chest pain.
Question 1 of 5
The nurse is preparing the client for the cardiac catheterization. Which of the following actions should the nurse take? (Select all that apply.)
Correct Answer: A,B,C
Rationale: Obtaining vital signs, witnessing the informed consent, and confirming allergies are necessary to monitor cardiovascular status, ensure consent, and prevent allergic reactions. Informing about risks is the provider's role, and marking the site is not required for cardiac catheterization.
Question 2 of 5
The nurse is preparing the client for the cardiac catheterization. Which of the following actions should the nurse take? (Select all that apply.)
Correct Answer: A,B,C
Rationale: Obtaining vital signs, witnessing the informed consent, and confirming allergies are necessary to monitor cardiovascular status, ensure consent, and prevent allergic reactions. Informing about risks is the provider's role, and marking the site is not required for cardiac catheterization.
Extract:
Question 3 of 5
A nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction. Which of the following doctor's orders should the nurse take first?
Correct Answer: B
Rationale: Initiating oxygen therapy is the priority action. Oxygen is critical in improving oxygenation and reducing myocardial stress during a myocardial infarction. It helps prevent further damage to the heart muscle and supports overall cardiac function.
Question 4 of 5
A nurse is caring for a client 4 hr following a cardiac catheterization. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: After a cardiac catheterization, the client is typically required to lie flat for several hours to prevent complications such as bleeding or hematoma formation at the catheter insertion site, especially if the femoral artery was used. This helps ensure the clotting process is not disturbed and reduces the risk of complications.
Extract:
Nurse's Notes
The client arrives to the ED and reports a "fluttering" and "racing" heartbeat. The client also reports dizziness and shortness of breath. Client placed on telemetry, cardiac rhythm is irregular, tachycardic and has unclear P waves.
A nurse is caring for a client in the emergency department (ED).
Question 5 of 5
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
| Acton to Take: Prepare the client for defibrillation |
| Obtain a 12 lead ECG |
| Teach the client how to perform vagal maneuver |
| Administer adenosine IV push |
| Administer an anticoagulant |
| Potential conditions A. Atrial fibrillation B. Supraventricular Tachycardia C. Ventricular fibrillation D. Ventricular tachycardia |
| Parameters to monitor A. Central nervous system side effects B. Manifestations of stroke C. Prolonged PR interval D. PT/INR E. Hypokalemia |
Correct Answer: A,B,E,B,D
Rationale: The client is likely experiencing atrial fibrillation, indicated by irregular, tachycardic rhythm and unclear P waves. Obtaining a 12-lead ECG and administering an anticoagulant are appropriate actions. Monitoring for stroke manifestations and PT/INR assesses progress and anticoagulant therapy effectiveness.