ATI RN
ATI Medical Surgical Proctored Exam
1. A client with a spinal cord injury at T6 suddenly reports a pounding headache and blurred vision. What action should the nurse take first?
- A. Administer pain medication as ordered.
- B. Check the client's blood pressure.
- C. Place the client in a supine position.
- D. Increase the client's fluid intake.
Correct answer: B
Rationale: The client's symptoms of a pounding headache and blurred vision are indicative of autonomic dysreflexia, a potentially life-threatening condition in clients with spinal cord injuries at T6 or above. The nurse's priority action should be to check the client's blood pressure as autonomic dysreflexia can lead to severe hypertension. Identifying and addressing this elevated blood pressure promptly is crucial to prevent serious complications such as seizures, stroke, or even death. Once the blood pressure is assessed and managed, further interventions can be implemented to address the underlying cause of autonomic dysreflexia.
2. During an acute asthma attack in a client with asthma, what medication should the nurse administer first?
- A. Oral corticosteroids
- B. Short-acting beta agonist
- C. Leukotriene receptor antagonist
- D. Long-acting beta agonist
Correct answer: B
Rationale: During an acute asthma attack, the priority is to quickly relieve bronchospasm and improve breathing. Short-acting beta agonists, like albuterol, are the first-line medications as they rapidly relax bronchial muscles, providing immediate relief. Oral corticosteroids are used as adjunct therapy to reduce airway inflammation over time, while leukotriene receptor antagonists and long-acting beta agonists are not appropriate for immediate relief during an acute attack.
3. A client had an inferior wall myocardial infarction (MI). The nurse notes the client's cardiac rhythm as shown below. What action by the nurse is most important?
- A. Assess the client's blood pressure and level of consciousness.
- B. Call the health care provider or the Rapid Response Team.
- C. Obtain a permit for an emergency temporary pacemaker insertion.
- D. Prepare to administer antidysrhythmic medication.
Correct answer: A
Rationale: The ECG strip shows sinus bradycardia, which is common in clients with an inferior wall MI. This rhythm can lead to decreased perfusion due to bradycardia and blocks. The most crucial initial action for the nurse is to assess the client's hemodynamic status, including blood pressure and level of consciousness. This assessment will help determine the immediate needs of the client. Calling the health care provider or the Rapid Response Team, obtaining a permit for a pacemaker insertion, or preparing to administer antidysrhythmic medication may be necessary based on the assessment findings, but the priority is to evaluate the client's current condition first.
4. The client with a chest tube after a coronary artery bypass graft has significantly slowed drainage. What action is most important for the nurse to take?
- A. Increase the setting on the suction.
- B. Notify the provider immediately.
- C. Re-position the chest tube.
- D. Take the tubing apart to assess for clots.
Correct answer: B
Rationale: If the drainage from the chest tube decreases significantly, it may indicate a blockage by a clot, potentially leading to cardiac tamponade. The nurse's priority action should be to notify the healthcare provider immediately for further evaluation and intervention. Increasing suction, re-positioning the chest tube, or disassembling the tubing independently are not appropriate actions without healthcare provider guidance in this situation.
5. Prior to a cardiac catheterization, what is the most important action for the nurse to take?
- A. Ensure that the client has been NPO for 6 hours before the procedure.
- B. Administer pre-procedure medications as ordered.
- C. Verify that informed consent has been obtained.
- D. Assess the client for any allergies, especially to iodine or shellfish.
Correct answer: D
Rationale: Assessing the client for allergies, particularly to iodine or shellfish, is crucial before a cardiac catheterization because the contrast dye used during the procedure can lead to allergic reactions. Identifying any allergies beforehand allows the healthcare team to take necessary precautions to prevent potential adverse reactions and ensure the client's safety.
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