ATI RN
ATI n269 Med Surg Comprehensive Exam Questions
Extract:
Question 1 of 5
Which assessment finding would the nurse expect in a patient diagnosed with acute pericarditis?
Correct Answer: D
Rationale: A pericardial friction rub is a hallmark sign of acute pericarditis. It occurs due to the inflammation of the pericardial layers, which rub against each other, producing a characteristic high-pitched, scratchy sound heard on auscultation.
Question 2 of 5
A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: The first action should be to check the client's vital signs. Nausea and weakness are common symptoms of digoxin toxicity, which can cause bradycardia, arrhythmias, and other life-threatening complications. Checking the vital signs, particularly the heart rate, is critical to assess if the client is experiencing digoxin toxicity.
Question 3 of 5
A nurse is assessing a client who has a left lower arm fracture. Which of the following findings indicates impaired venous return in the client's affected arm?
Correct Answer: B
Rationale: Increasing edema is a key sign of impaired venous return. When the veins are not effectively draining blood, fluid accumulates in the tissues, causing swelling. This is a critical sign of venous insufficiency or compromised circulation.
Question 4 of 5
A nurse is caring for a client who just had a flexible bronchoscopy. Which of the following nursing actions is appropriate?
Correct Answer: A
Rationale: After a flexible bronchoscopy, the gag reflex may be temporarily impaired due to local anesthesia. It is important to withhold food and liquids until the gag reflex returns to prevent aspiration. This is the priority action to ensure the client's safety.
Question 5 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.