Questions 85

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ATI RN Adult Medical Surgical 2023 Questions Correct Answers Questions

Extract:

Client reports tightness in chest radiating to the left arm. Pain level: 7/10. Feels nauseous after breakfast. Client states: 'I had scrambled eggs and bacon like I do every morning.' Symptoms: Diaphoresis, shortness of breath, irregular and tachycardic heart rate. Neurological Status: Alert and oriented to person, place, and time. Lung Sounds: Clear in all lobes. Bowel Sounds: Present in all 4 quadrants. Peripheral Circulation: +1 pedal pulses, skin cool to touch, capillary refill <2 seconds.


Question 1 of 5

Which actions should the nurse take? (Select all that apply)

Correct Answer: A, B, D,E

Rationale: The nurse should anticipate cardiac catheterization prep (
A) to ensure client readiness. Continuous heparin infusion (
B) prevents clot formation during the procedure. Increased metoprolol dosage (
D) may be needed for cardiac stability. NPO status (E) is crucial to prevent complications during the procedure. Ambulation (
C) may be contraindicated due to the invasive nature of the procedure. Antibiotics (F) are not routinely needed for cardiac catheterization prep.

Extract:

Client reports tightness in chest radiating to the left arm.

Pain level: 7/10. Feels nauseous after breakfast.
Client states: 'I had scrambled eggs and bacon like I do every morning.'
Symptoms: Diaphoresis, shortness of breath, irregular and tachycardic heart rate.
Neurological Status: Alert and oriented to person, place, and time.
Lung Sounds: Clear in all lobes.
Bowel Sounds: Present in all 4 quadrants.
Peripheral Circulation: +1 pedal pulses, skin cool to touch, capillary refill <2 seconds.

Vital Signs (1000 Hours)

Temperature: 37.1°C (98.8°F). Heart Rate: 110/min, irregular. Respiratory Rate: 24/min. Blood Pressure: 164/80 mmHg. Oxygen Saturation: 93% on room air

Vital Signs (1015 Hours)

Temperature: 36.7°C (98.2°F). Heart Rate: 120/min, irregular. Respiratory Rate: 22/min. Blood Pressure: 176/82 mmHg. Oxygen Saturation: 89% on room air.

Diagnostic Results

Myoglobin: 100 mcg/L (high, normal <90 mcg/L), Creatine kinase: 180 units/L (normal, 55-170 units/L), Troponin T: 0.40 ng/mL (high, normal <0.1 ng/mL), Troponin I: 0.35 ng/mL (high, normal <0.03 ng/mL), Cholesterol: 244 mg/dL (high, normal <200 mg/dL), Triglycerides: 180 mg/dL (normal, 40-160 mg/dL), LDL: 148 mg/dL (high, normal <130 mg/dL), HDL: 42 mg/dL (good, normal >45 mg/dL), C-reactive protein: 2 mg/L (high, normal <1.0 mg/L), Blood glucose: 103 mg/dL (normal, 74-106 mg/dL), EKG: Tachycardia with ST segment elevation & T wave changes, Chest X-ray: Lungs clear in all lobes.

Provider's Prescriptions - 1020:
Nitroglycerin 0.5 mg SL every 5 min up to 3 doses for chest pain
Aspirin 160 mg PO daily - Morphine 6 mg IV bolus every 3 hr PRN pain
Metoprolol 25 mg PO every 6 hrs x 48 hrs, then 100 mg PO twice daily
Initiate IV site - 0.9% saline at 50 mL/hr IV infusion
Oxygen at 2 L/min via nasal cannula if oxygen saturation <90%
Schedule stat echocardiogram

Follow-up (1200 Hours)
Pain now 5/10 after two doses of nitroglycerin. Breathing easier with oxygen at 2L/min via nasal cannula.


Question 2 of 5

Which findings indicate the client's condition has improved? (Select all that apply)

Correct Answer: A, B

Rationale: The correct answers are A and B. Pain level indicates the client's subjective improvement, while respiratory rate reflects their physiological status. Pain reduction suggests improved comfort and possibly better overall health, while a decrease in respiratory rate may indicate improved oxygenation and reduced stress.

Choices C, D, E, F, and G are not directly linked to the client's overall condition improvement as they can vary for several reasons, independent of the client's actual health status.

Extract:


Question 3 of 5

A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Which of the following findings require immediate follow-up?

Correct Answer: B

Rationale: The correct answer is B: Heart rate 110/min and irregular. This finding suggests cardiac distress or arrhythmia, which could indicate a heart attack. Immediate follow-up is necessary to assess the client's cardiac status and intervene promptly.
Incorrect choices:
A: Temperature within normal range.
C: Respiratory rate within normal range.
D: Blood pressure slightly elevated but not an immediate concern.
E: Oxygen saturation slightly low but not critically low.

Question 4 of 5

A nurse is caring for a client who has COPD. Which of the following findings require immediate follow-up?

Correct Answer: D

Rationale: The correct answer is D. Tachypnea, productive cough with yellow mucus in a client with COPD indicate a potential exacerbation requiring immediate follow-up. Tachypnea suggests respiratory distress, while yellow mucus may indicate infection. Prompt intervention can prevent worsening respiratory status.

Choices A, B, and C do not indicate acute respiratory distress. Option E may be concerning but doesn't necessitate immediate intervention like option D does.

Question 5 of 5

A nurse is caring for a client who is experiencing an exacerbation of heart failure. Thenurse is assessing the client 24 hr later. How should the nurse interpret the findings related to the diagnosis of heart failure? For each finding, click to specify whe ther the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition. Diagnostic Results Hgb 8.4 g/dL (12 to 18 g/dL) Hct 42% (37% to 47%) WBC count 9,800/mm3 (5,000 to 10,000/ mm3) Potassium 432 mEq/L (3.5 to 5 mEq/L)

Findings 24 hr laterunrelated to the diagnosisPotential improvementWorsening condition
Lung sounds clean
Creatinine 1.8 mm/dl
Weight 113kg(249 lb)
WBC Count 11,800mm3
Temperature: 38.5°C (101.3°F)
Shortness of breath with exertion

Correct Answer: A, B,C,D,E

Rationale:
The correct answer is A, B, C, D, E. In heart failure exacerbation, key indicators are related to fluid overload and organ perfusion.
A) Lung sounds clean indicate potential improvement in pulmonary congestion.
B) Creatinine 1.8 mm/dl is important for kidney function monitoring, as worsening kidney function can occur in heart failure.
C) Weight 113kg reflects fluid retention, relevant for heart failure management.
D) WBC count (11,800mm3) can indicate infection, which can worsen heart failure. E) Temperature 38.5°C can suggest infection or systemic inflammatory response, which worsens heart failure.

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