ATI RN
ATI RN Adult Medical Surgical Online Practice 2023 A
1. A client presents with shortness of breath, pain in the lung area, and a recent history of starting birth control pills and smoking. Vital signs include a heart rate of 110/min, respiratory rate of 40/min, and blood pressure of 140/80 mm Hg. Arterial blood gases reveal pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. What is the priority nursing intervention?
- A. Prepare for mechanical ventilation.
- B. Administer oxygen via face mask.
- C. Prepare to administer a sedative.
- D. Assess for indications of pulmonary embolism.
Correct answer: Administer oxygen via face mask.
Rationale: In a client with a high respiratory rate, low PaO2, and low SaO2, the priority intervention is to improve oxygenation. Administering oxygen via a face mask will help increase the oxygen supply to the client's lungs and tissues, addressing the hypoxemia. While mechanical ventilation may be necessary in severe cases, administering oxygen is the initial and most appropriate intervention to address the client's respiratory distress. Sedatives should not be given without ensuring adequate oxygenation. Assessing for pulmonary embolism is important but not the priority at this moment when the client is experiencing respiratory distress and hypoxemia.
2. What are the pressure-sensitive structures located in the aortic and carotid bodies called?
- A. Baroreceptors
- B. Chemoreceptors
- C. Nociceptors
- D. Mechanoreceptors
Correct answer: A
Rationale: Baroreceptors are the correct answer. Baroreceptors are specialized sensory receptors that detect changes in pressure within blood vessels. They are primarily located in the aortic arch and carotid sinuses, where they play a crucial role in regulating blood pressure. Chemoreceptors (Choice B) are receptors that detect chemical changes, not pressure changes. Nociceptors (Choice C) are responsible for detecting painful stimuli. Mechanoreceptors (Choice D) respond to mechanical stimuli such as touch, pressure, and vibration, but they are not specifically located in the aortic and carotid bodies.
3. A client reports pain and swelling at the IV site. What should the nurse do first?
- A. Flush the IV line and continue the infusion.
- B. Stop the infusion and notify the healthcare provider.
- C. Increase the IV infusion rate to reduce discomfort.
- D. Apply a warm compress to the IV site and continue monitoring.
Correct answer: B
Rationale: The correct answer is B: Stop the infusion and notify the healthcare provider. Pain and swelling at an IV site can indicate infiltration or infection, which are serious complications. Stopping the infusion helps prevent further harm to the client, and notifying the healthcare provider promptly allows for appropriate assessment and intervention. Choice A is incorrect because flushing the IV line and continuing the infusion could exacerbate the issue. Choice C is incorrect as increasing the IV infusion rate is not the appropriate action for pain and swelling at the site. Choice D is incorrect because applying a warm compress may not address the underlying issue of infiltration or infection; it's crucial to stop the infusion and seek further guidance.
4. A client with an indwelling urinary catheter is being cared for by a nurse. What finding indicates a catheter occlusion?
- A. Bladder distention
- B. Frequent urination
- C. Hematuria
- D. Burning sensation
Correct answer: A
Rationale: Bladder distention is the correct answer as it indicates that the catheter is not draining properly, which is a sign of occlusion. Frequent urination, hematuria, and burning sensation are not indicative of a catheter occlusion. Frequent urination may suggest a bladder that is not fully emptying, hematuria indicates blood in the urine, and a burning sensation can be a sign of a urinary tract infection, none of which directly relate to a catheter occlusion.
5. Which client action is an example of the defense mechanism of displacement?
- A. A man kicks his dog after an argument with his boss.
- B. A woman yells at her children after a stressful day at work.
- C. A student immerses herself in studying to avoid thinking about a recent breakup.
- D. A person channels aggressive impulses into playing a sport.
Correct answer: B
Rationale: Displacement involves redirecting emotions, often anger or aggression, from their original source to a less threatening target. In this scenario, the woman redirects her frustration from work towards her children, who are perceived as less threatening and safer to express anger towards.
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