ATI RN
ATI n269 Med Surg Comprehensive Exam Questions
Extract:
Nurses notes
Laboratory
Diagnostic Results
Vital Signs
Two weeks ago
0900:
Received client alert and oriented. Lung sounds with crackles bilaterally, respirations with dyspnea observed on exertion. Heart sounds with S3 auscultated. 1+ jugular venous distention. Capillary refill in 3 seconds in bilateral upper and in 4 seconds in bilateral lower extremities. Pulses in bilateral upper extremities at +2; pulses in bilateral lower extremities +1 and cool to touch with +1 pitting edema.
Client reports worsening shortness of breath over the last couple of months. Client states "I thought I was just gaining weight, but I think my heart may not be working right." Client also reports that both their legs are swollen, and they get short of breath while walking or doing any type of activity. Denies chest pain or palpitations and reports blood pressure is controlled.
Today
0830:
Follow-up appointment with client who reports feeling a little better. Lung sounds clear bilaterally, respirations with dyspnea observed on exertion. Heart sounds with S3 auscultated. Jugular vein distention absent. Capillary refill in 3 seconds in bilateral upper extremities and in 4 seconds in bilateral lower extremities. Pulses in bilateral upper and lower extremities at +2 and no edema to extremities. Skin warm and dry to touch, color appropriate for genetic background. Client reports less shortness of breath, but admits they still get a "little winded when doing activities."
Question 1 of 5
The nurse is reviewing the client's assessment findings. Which of the following findings indicates that the client's condition has improved or has not changed since their two-week follow-up appointment?
| Options | Improved | No change |
|---|---|---|
| Blood Pressure | ||
| Jugular Venous Distention | ||
| Lung sounds | ||
| Serum Potassium | ||
| Weight | ||
| Dyspnea | ||
| Oxygen saturation |
Correct Answer: A,B,C,D,E
Rationale: Blood pressure, jugular venous distention, lung sounds, serum potassium, and weight have improved, indicating better heart failure management. Dyspnea and oxygen saturation remain unchanged, showing no worsening.
Extract:
Question 2 of 5
A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: Dehydration is a common finding in diabetes insipidus. The condition causes excessive urination (polyuria) due to a deficiency of antidiuretic hormone (ADH) or resistance to it, leading to a significant loss of water and subsequent dehydration if fluid intake is not sufficient to compensate.
Question 3 of 5
A nurse is completing discharge teaching with a client following arthroscopic knee surgery. Which of the following instructions should the nurse include in the teaching?
Correct Answer: A
Rationale: Applying ice to the affected area is recommended after arthroscopic knee surgery to reduce swelling and pain. Ice helps control inflammation and promotes healing.
Question 4 of 5
A nurse is assessing for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: A decrease in systolic pressure by more than 10 mm Hg during inspiration is a classic sign of paradoxical blood pressure, which can occur in conditions such as constrictive pericarditis. This occurs because the pressure within the pericardium prevents the heart from expanding fully during inspiration, leading to a drop in systolic blood pressure.
Question 5 of 5
A nurse is interpreting the ECG strip of a client who has bradycardia. Which of the following cardiac components should the nurse identify as the role of the P wave?
Correct Answer: A
Rationale: The P wave represents atrial depolarization. It is the electrical impulse that triggers the contraction of the atria. The P wave is the first wave in the ECG cycle and indicates the initiation of the heart's electrical activity from the sinoatrial (S
A) node.