ATI RN
ATI Medsurg Exam 5 Questions
Extract:
Question 1 of 5
The nurse is preparing to assess the blood pressure on a client. Which of the following should be the appropriate guidelines when selecting the correct blood pressure cuff size?
Correct Answer: B
Rationale: The cuff's rubber bladder width should be approximately 40% of the arm circumference to ensure accurate blood pressure measurement. Incorrect cuff sizes can lead to false readings.
Question 2 of 5
The nurse documents the blood pressure on a client to be 158/94 mm Hg when lying in bed, 13 mm Hg when sitting in a chair, and 98/60 mm Hg when standing. The nurse should recognize which of the following as the evaluation of this?
Correct Answer: A
Rationale: The significant drop in blood pressure upon standing indicates orthostatic hypotension, not hypertension or normal variation.
Question 3 of 5
The nurse is caring for an older adult client in the emergency room diagnosed with dehydration after being found lying on the floor for 2 days. Which of the following assessment findings should the nurse expect on a dehydrated client?
Correct Answer: A
Rationale: Dehydration causes dry mucous membranes and lips due to reduced fluid levels, unlike pale membranes, smooth lips, or white patches, which indicate other conditions.
Question 4 of 5
The nurse is assessing the quality of a client's pain. Which of the following should be the appropriate question by the nurse?
Correct Answer: B
Rationale: Asking 'What does your pain feel like?' allows the client to describe pain quality comprehensively, unlike limiting or time-focused questions.
Question 5 of 5
The nurse is assessing the intensity of a client's pain. Which of the following should be the appropriate question by the nurse?
Correct Answer: B
Rationale: Asking 'How much pain do you have now?' directly assesses pain intensity, unlike questions about function, quality, or aggravating factors.