ATI RN
ATI Medical Surgical Proctored Exam
1. 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.
2. A client with end-stage heart failure who is awaiting a transplant appears depressed and states, 'I know a transplant is my last chance, but I don't want to become a vegetable.' How should the nurse respond?
- A. Would you like information about advance directives?
- B. I will arrange for a psychiatrist to speak with you.
- C. Do you want to come off the transplant list?
- D. Would you like to speak with a priest or chaplain?
Correct answer: A
Rationale: The client is expressing a fear of negative outcomes related to the transplant. By offering information about advance directives, the nurse allows the client to discuss concerns and preferences for end-of-life care. This response shows empathy, acknowledges the client's autonomy, and addresses the client's fears while providing support and information.
3. A client with a history of gastrointestinal bleeding is taking warfarin (Coumadin). Which instruction should the nurse include in the teaching plan?
- A. Avoid eating foods high in vitamin K.
- B. Take aspirin for pain relief.
- C. Report any signs of bruising or bleeding to your healthcare provider.
- D. Limit fluid intake to 2 liters per day.
Correct answer: C
Rationale: The correct instruction for a client taking warfarin, an anticoagulant, is to report any signs of bruising or bleeding to the healthcare provider promptly. This is crucial as these symptoms may indicate over-anticoagulation, which can lead to serious complications. Monitoring for signs of bleeding is essential to adjust the medication dosage or take appropriate measures to ensure the client's safety.
4. A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed assistive personnel (UAP). Four hours later, the nurse notes the client's blood pressure is much higher than previous readings & the client's mental status has changed. What action by the nurse would most likely have prevented this negative outcome?
- A. Determining if the UAP knew how to take blood pressure
- B. Double-checking the UAP by taking another blood pressure
- C. Providing more appropriate supervision of the UAP
- D. Taking the blood pressure instead of delegating the task
Correct answer: C
Rationale: The most likely action by the nurse that would have prevented the negative outcome is providing more appropriate supervision of the UAP. Supervision is essential in delegation as it involves directing, evaluating, and following up on delegated tasks. By providing adequate supervision, the nurse can ensure that tasks are performed correctly and promptly identify any issues or abnormalities, such as a significant change in vital signs or the client's mental status. This proactive approach can help prevent adverse outcomes and enhance patient safety.
5. A healthcare professional wishes to provide client-centered care in all interactions. Which action by the healthcare professional best demonstrates this concept?
- A. Assesses for cultural influences affecting healthcare
- B. Ensures that all the client's basic needs are met
- C. Informs the client and family about all upcoming tests
- D. Thoroughly orients the client and family to the room
Correct answer: A
Rationale: Client-centered care focuses on individualizing care to meet the client's unique needs, preferences, and values. Assessing for cultural influences affecting healthcare allows the healthcare professional to provide culturally sensitive and competent care, respecting the client's beliefs and practices. It promotes effective communication, understanding, and collaboration, essential components of client-centered care.
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