ATI RN
ATI RN Adult Medical Surgical 2023 Questions Correct Answers Questions
Extract:
Question 1 of 5
Which of the following findings should the nurse identify as a contraindication to receiving this alternative therapy?
Correct Answer: B
Rationale: The correct answer is B: Lymphedema. Lymphedema is a swelling caused by a lymphatic system blockage, which can be worsened by some alternative therapies. Headaches, mouth sores, and urticaria are symptoms that may not necessarily contraindicate alternative therapy. Lymphedema can cause complications if not managed properly, making it a clear contraindication.
Question 2 of 5
A nurse is providing instructions about foot care for a client who has peripheral arterial disease. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: A
Rationale: The correct answer is A because applying a lubricating lotion to the cracked areas on the soles of the feet helps prevent further skin breakdown and infection, which is crucial in peripheral arterial disease.
Choice B may improve circulation, but it does not address foot care directly.
Choice C can lead to burns or injury due to decreased sensation in peripheral arterial disease.
Choice D poses a risk of injury or infection due to the potential for skin damage while soaking the feet. Overall, choice A is the most appropriate for maintaining foot health in peripheral arterial disease.
Question 3 of 5
A nurse is preparing a teaching plan for a client who has mucositis related to chemotherapy treatment. Which of the following instructions should the nurse include?
Correct Answer: B
Rationale: The correct answer is B: Wear your dentures only during meals. This instruction is important for a client with mucositis because wearing dentures continuously can exacerbate irritation and discomfort in the mouth. By removing dentures between meals, the client can allow the oral tissues to rest and promote healing.
Choice A is incorrect because vigorous brushing for 60 seconds can further irritate the mucositis.
Choice C is incorrect as flossing can also cause trauma to the inflamed tissues.
Choice D is incorrect as rinsing with hydrogen peroxide can be too harsh and may worsen the condition. It's important to provide gentle care and minimize irritation to the affected areas in mucositis.
Question 4 of 5
A nurse is monitoring a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a manifestation of Cushing's triad?
Correct Answer: A
Rationale: The correct answer is A: Increase in blood pressure from 130/80 mm Hg to 180/100 mm Hg. Cushing's triad is a set of three classic signs indicating increased intracranial pressure (ICP). The triad includes hypertension (widening pulse pressure), bradycardia, and irregular respirations. In this case, an increase in blood pressure is consistent with the hypertension component of Cushing's triad. This occurs due to the body's compensatory mechanism to maintain perfusion to the brain in response to increased ICP.
Choices B, C, D, and E do not align with the classic signs of Cushing's triad. Bradycardia, not a decrease in heart rate, is typically seen in Cushing's triad. Rapid and shallow respirations are not part of the triad. Hypotension is not a characteristic finding in Cushing's triad.
Question 5 of 5
A nurse is caring for a client who has acute angina. Which of the following actions should the nurse take first?
Correct Answer: B
Rationale: The correct answer is B: Administer aspirin. Administering aspirin is the priority action for a client with acute angina as it helps in reducing platelet aggregation and improving blood flow to the heart. This action can potentially prevent further clot formation and decrease the risk of a heart attack. It is essential to address the acute symptoms first before proceeding with other interventions. Measuring blood pressure (
A), administering nitroglycerin (
C), and initiating IV access (
D) are important actions but administering aspirin takes precedence in this scenario to address the acute angina symptoms promptly.