ATI Medical Surgical Proctored Exam

ATI Medical Surgical Proctored Exam Related

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A client with chronic obstructive pulmonary disease (COPD) who has been receiving oxygen therapy at 2 L/min now has a respiratory rate of 10 breaths/min. What action should the nurse take first?

  • A. Increase the oxygen flow rate to 4 L/min.
  • B. Administer a bronchodilator via nebulizer.
  • C. Encourage the client to take deep breaths.
  • D. Assess the client's mental status and level of consciousness.
Correct Answer: D

Rationale: The correct answer is D, assessing the client's mental status and level of consciousness. This is the first action to take because a respiratory rate of 10 breaths/min in a COPD client receiving oxygen therapy may indicate respiratory depression or impending respiratory failure. Assessing mental status and level of consciousness can help determine if the client is experiencing hypoxia. Increasing oxygen flow rate (A) without assessing the client first can be dangerous if the client is retaining carbon dioxide. Administering a bronchodilator (B) may not address the underlying issue of respiratory depression. Encouraging deep breaths (C) may not be appropriate if the client is in respiratory distress.

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What should the nurse do while dealing with older adults who lose the ability to hear at high-pitched ranges?

  • A. Lower the voice pitch.
  • B. Insert a stethoscope in the client’s ears.
  • C. Use a magic slate or chalkboard.
  • D. Ensure that the hearing aid is in good working order.
Correct Answer: A

Rationale: Lowering the voice pitch accommodates age-related hearing loss, improving communication clarity.

For a patient on the chemotherapeutic drug vincristine (Oncovin), which of the following side effects should be reported to the physician?

  • A. Fatigue.
  • B. Nausea and vomiting.
  • C. Paresthesia.
  • D. Anorexia.
Correct Answer: C

Rationale: Paresthesia is a serious neurotoxic side effect of vincristine and requires immediate medical attention.

A nurse is caring for a client post-myocardial infarction (MI). What is the priority assessment for this client?

  • A. Monitoring urine output
  • B. Checking blood glucose levels
  • C. Assessing for chest pain
  • D. Monitoring electrolyte levels
Correct Answer: C

Rationale: The correct answer is C: Assessing for chest pain. The priority assessment for a client post-MI is to monitor for any signs of recurrent chest pain or angina, as it could indicate ongoing cardiac ischemia or a new infarction. Prompt intervention is crucial in these situations to prevent further damage to the heart muscle. Monitoring urine output (A) and electrolyte levels (D) are important assessments but do not take precedence over assessing for chest pain. Checking blood glucose levels (B) is relevant for diabetic clients but is not the priority in this case.

In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey?

  • A. Complete set of vital signs
  • B. Palpation and auscultation of the abdomen
  • C. Brief neurologic assessment
  • D. Initiation of pulse oximetry
Correct Answer: C

Rationale: A brief neurologic assessment helps quickly identify potential brain injuries or other neurological deficits.

A patient who had major surgery is experiencing emotional stress as well as physiologic stress from the effects of surgery. What can this stress cause?

  • A. Diuresis
  • B. Hyperkalemia
  • C. Fluid retention
  • D. Impaired blood coagulation
Correct Answer: C

Rationale: Surgical stress triggers hormonal responses leading to fluid retention.

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