ATI RN
ATI Medical Surgical Proctored Exam
1. When caring for an older adult client with a pulmonary infection, what action should the nurse take first?
- A. Encourage the client to increase fluid intake.
- B. Assess the client's level of consciousness.
- C. Raise the head of the bed to at least 45 degrees.
- D. Provide the client with humidified oxygen.
Correct answer: B
Rationale: Assessing the client's level of consciousness is the priority because it provides crucial information on the client's neurological status and response to the infection. Changes in consciousness can indicate deterioration or improvement in the client's condition, guiding further interventions and treatment.
2. A client diagnosed with major depressive disorder is prescribed an SSRI. Which side effect should the nurse monitor for in the initial weeks of treatment?
- A. Weight loss
- B. Increased risk of suicide
- C. Hypertension
- D. Photosensitivity
Correct answer: B
Rationale: When a client is prescribed an SSRI for major depressive disorder, the nurse should closely monitor for an increased risk of suicide, especially in younger patients, during the initial weeks of treatment. SSRIs may initially increase energy levels before improving mood, which can lead to a higher risk of suicide in some individuals. Weight loss is not a common side effect of SSRIs and may actually be a concern for some patients with major depressive disorder who experience appetite changes. Hypertension is not typically associated with SSRIs, and photosensitivity is not a common side effect of this class of medications.
3. After surgery, a patient is experiencing pain. What is the nurse's priority action?
- A. Administer pain medication as prescribed.
- B. Assess the patient's pain using a pain scale.
- C. Offer the patient non-pharmacological pain relief methods.
- D. Reassess the patient's pain level after 30 minutes.
Correct answer: B
Rationale: The correct answer is to assess the patient's pain using a pain scale. This is the priority action because it allows the nurse to obtain an objective measure of the patient's pain intensity. By accurately assessing the pain level, the nurse can determine the appropriate intervention, which may include administering pain medication as prescribed (choice A) or offering non-pharmacological pain relief methods (choice C). Reassessing the patient's pain level after 30 minutes (choice D) is important but comes after the initial assessment to evaluate the effectiveness of the interventions implemented.
4. During the Emergent phase of a burn, the most fatal electrolyte imbalance in a burned client is:
- A. Hypokalemia
- B. Hyperkalemia
- C. Hypernatremia
- D. Hyponatremia
Correct answer: A
Rationale: During the Emergent phase of burns, the most fatal electrolyte imbalance is Hypokalemia. This is due to the shift of potassium from the intracellular space to the extracellular space, leading to low potassium levels in the blood. Choices B, C, and D are incorrect because Hyperkalemia, Hypernatremia, and Hyponatremia are not typically associated with the Emergent phase of burns and do not pose the same level of risk as Hypokalemia in this context.
5. Which of the following are effective strategies to become more resilient? (EXCEPT)
- A. Exercising and avoiding high-fat foods.
- B. Managing time effectively.
- C. Becoming more self-aware.
- D. Deciding that your career is not your highest priority.
Correct answer: D
Rationale: Resilience can be enhanced through various strategies such as exercising, managing time effectively, and becoming more self-aware. Deciding that your career is not your highest priority may not necessarily contribute to building resilience as it does not directly address the personal traits and coping mechanisms associated with resilience. This choice focuses more on prioritization rather than the specific skills and mindset needed to bounce back from challenges. Sherman's study (2004) highlighted the importance of self-awareness in preventing burnout among nurses, emphasizing the value of self-care and personal well-being in maintaining resilience.
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