Medical Surgical ATI Proctored Exam

Medical Surgical ATI Proctored Exam Related

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A client with acute respiratory failure (ARF) is being cared for by a nurse. The nurse should monitor the client for which of the following manifestations of this condition?

  • A. Severe dyspnea
  • B. Nausea
  • C. Decreased level of consciousness
  • D. Headache
Correct Answer: B

Rationale: The correct answer is B: Nausea. In acute respiratory failure (ARF), the body may compensate by increasing respiratory rate, leading to respiratory alkalosis. This can cause nausea due to the altered pH levels affecting the chemoreceptors in the brain. Severe dyspnea (choice A) is a common symptom of ARF but does not specifically relate to nausea. Decreased level of consciousness (choice C) may indicate severe hypoxemia but is not a direct manifestation of ARF. Headache (choice D) is more commonly associated with conditions like hypoxia, hypercapnia, or respiratory acidosis in ARF.

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What are the criteria for diagnosing systemic inflammatory response syndrome (SIRS)?

  • A. Dehydration
  • B. Overhydration
  • C. Electrolyte imbalance
  • D. Hypertension
Correct Answer: A

Rationale: Dehydration results from fluid loss exceeding intake, causing symptoms like dry mucous membranes, poor skin turgor, and hypotension.

Why should the nurse assess current weight status and recent weight fluctuations in a client with anxiety?

  • A. Weight fluctuations indicate impaired kidney function in clients with anxiety
  • B. All clients with anxiety lose weight rapidly
  • C. Antianxiety drugs increase appetite
  • D. Some clients may react to stress by overeating
Correct Answer: D

Rationale: Clients may overeat or lose appetite due to stress, affecting their weight and overall health.

Several cultural groups avoid direct eye contact and consider it disrespectful or aggressive. Which cultural group may not return a direct gaze?

  • A. Arab
  • B. Asian
  • C. Hispanic
  • D. Native American
Correct Answer: B

Rationale: In many Asian cultures, avoiding direct eye contact signifies respect, particularly toward authority figures or elders.

8. What is acupuncture used for (select all that apply)?

  • A. Relieve pain by causing counterirritation in another area of the body.
  • B. Reestablish the flow of Qi through meridians to simulate the body’s self-healing mechanism.
  • C. Create an inflammatory response at an acupoint, increasing blood circulation and healing energy.
  • D. Relieve nausea and vomiting postoperatively, with pregnancy, or related to chemotherapy.
Correct Answer: B

Rationale: Acupuncture is commonly used to reestablish the flow of Qi (option B) and relieve nausea and vomiting (option D), among other therapeutic uses.

A client in the intensive care unit is receiving teaching before removal of an endotracheal tube. Which of the following instructions should the nurse include in the teaching?

  • A. Rest in a side-lying position after the tube is removed.
  • B. Use the incentive spirometer every 4 hours after the tube is removed.
  • C. Avoid speaking for extended periods.
  • D. Vital signs will be monitored by a nurse every 15 minutes in the first hour after the tube is removed.
Correct Answer: C

Rationale: The correct answer is C: Avoid speaking for extended periods. This instruction is important to prevent strain on the vocal cords and reduce the risk of aspiration or airway irritation post-extubation. Speaking after the removal of the endotracheal tube can potentially lead to complications.

Step-by-step rationale:
1. Speaking can cause strain on the vocal cords, which may lead to hoarseness or damage.
2. It is essential to allow the airway to recover and prevent irritation or inflammation.
3. Resting the voice can aid in the healing process and reduce the risk of complications.
4. Incentive spirometer use (option B) is important for lung expansion but not directly related to vocal cord rest.
5. Vital signs monitoring (option D) is crucial but does not address vocal cord care or prevention of complications.
6. Resting in a side-lying position (option A) is not directly related to vocal cord rest or post-extubation care.

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