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ATI RN & PN Medical Surgical Nursing Exam Version 3–
Adult Health Disorders and Nursing Interventions
Updated and Latest Questions and Correct Answers with
Rationale
1. A nurse is caring for a client with heart failure who is prescribed Digoxin and Furosemide. Which of the following findings should the nurse prioritize as a potential complication of this combination? A. A blood pressure of 110/70 mmHg B. A serum potassium level of 3.2 mEq/L C. A heart rate of 72 beats per minute D. A serum digoxin level of 1.1 ng/mL Ans: B Rationale: Hypokalemia is a critical risk factor for clients taking both Furosemide and Digoxin. Furosemide is a loop diuretic that causes the excretion of potassium, which can lead to low serum potassium levels. When potassium levels are low, the heart becomes more sensitive to the effects of Digoxin, significantly increasing the risk of Digoxin toxicity. The nurse must monitor for symptoms like visual changes, nausea, and bradycardia. A potassium level of 3.2 mEq/L is below the normal range of 3. to 5.0 mEq/L and requires immediate intervention. Correcting the potassium deficit is essential to prevent life-threatening cardiac arrhythmias. The nurse should advocate for potassium supplements or a potassium-sparing diuretic if appropriate. Continuous ECG monitoring may be indicated until the electrolyte imbalance is resolved.
2. A client is admitted with an acute exacerbation of COPD. The arterial blood gas (ABG) results are: pH 7.30, PaCO2 52 mmHg, and HCO3 28 mEq/L. How should the nurse interpret these findings? A. Uncompensated Metabolic Acidosis B. Uncompensated Respiratory Acidosis C. Fully Compensated Respiratory Alkalosis D. Partially Compensated Respiratory Acidosis Ans: D Rationale: The pH of 7.30 indicates acidosis as it is below the normal range of 7.35 to 7.45. The PaCO2 of 52 mmHg is elevated, which is the primary cause of the acidic pH in respiratory conditions. The HCO level of 28 mEq/L is elevated above the normal range of 22 to 26 mEq/L. This elevation in bicarbonate indicates that the kidneys are attempting to compensate for the respiratory acidosis. Because the pH has not yet returned to the normal range, the compensation is considered partial. If the pH were within 7. to 7.45, it would be considered fully compensated. The nurse must monitor the client’s respiratory status and provide oxygen therapy cautiously to avoid suppressing the respiratory drive.
4. Which assessment finding in a client with a head injury should the nurse report immediately as an early sign of increased intracranial pressure (ICP)? A. Cushing’s triad (widened pulse pressure, bradycardia, irregular respirations) B. Decreased level of consciousness (LOC) or agitation C. Dilated and fixed pupils D. Decerebrate posturing Ans: B Rationale: A change in the level of consciousness is often the very first sign of increased intracranial pressure. This may manifest as subtle agitation, restlessness, or confusion before more severe signs appear. Cushing’s triad is a late sign of ICP and indicates that brain herniation may be imminent. Similarly, fixed and dilated pupils or decerebrate posturing are ominous late findings that suggest significant brain stem involvement. Early detection is vital for the nurse to implement interventions such as elevating the head of the bed to 30 degrees. The nurse must perform frequent neurological checks using the Glasgow Coma Scale. Timely reporting allows for medical interventions like mannitol administration or surgical decompression. Any delay in recognizing subtle LOC changes can result in irreversible neurological damage.
5. A client with Chronic Kidney Disease (CKD) has a serum potassium level of 6.8 mEq/L. Which medication should the nurse anticipate administering first to protect the heart? A. Sodium Polystyrene Sulfonate (Kayexalate) B. Furosemide C. Regular Insulin and Dextrose 50% D. Calcium Gluconate Ans: D Rationale: A potassium level of 6.8 mEq/L is a medical emergency that can cause lethal cardiac arrhythmias. While several medications help lower potassium, Calcium Gluconate is given first to stabilize the myocardial cell membrane. It does not lower the potassium level itself but protects the heart from the toxic effects of hyperkalemia. After stabilizing the heart, the nurse would expect to give Insulin and Dextrose to shift potassium into the cells. Sodium Polystyrene Sulfonate (Kayexalate) is used to actually remove potassium from the body via the GI tract, but it acts slowly. Hemodialysis is often the definitive treatment for severe hyperkalemia in CKD patients. The nurse must continuously monitor the client’s ECG for peaked T waves or widened QRS complexes. Rapid intervention is necessary to prevent cardiac arrest in these high-risk clients.
7. A client is 4 hours post-operative following an open reduction internal fixation (ORIF) of the right tibia. Which finding is most indicative of compartment syndrome? A. Serosanguinous drainage on the surgical dressing B. Diminished pedal pulses in the affected extremity C. Pain that is unrelieved by prescribed opioid analgesics D. A capillary refill of 2 seconds in the right toes Ans: C Rationale: Pain out of proportion to the injury and unrelieved by medication is a classic early sign of compartment syndrome. Compartment syndrome occurs when increased pressure within a confined space compromises circulation. This leads to ischemia and potential necrosis of the muscles and nerves. While diminished pulses (pulselessness) and pallor are signs, they are usually very late findings and indicate advanced damage. The nurse must perform the ‘6 Ps’ assessment: pain, pressure, paralysis, paresthesia, pallor, and pulselessness. If compartment syndrome is suspected, the nurse should notify the surgeon immediately for a potential fasciotomy. It is crucial not to elevate the limb above heart level, as this can further decrease arterial perfusion. Prompt recognition can save the limb from permanent functional loss or amputation. Continuous neurovascular monitoring is the standard of care for post- operative orthopedic patients.
8. A client with a suspected Myocardial Infarction (MI) arrives at the emergency department. Which of the following should be the nurse’s first action? A. Obtain a 12-lead Electrocardiogram (ECG) B. Administer Morphine IV for pain relief C. Draw blood for cardiac enzymes (Troponin) D. Administer high-flow oxygen via non-rebreather mask Ans: A Rationale: Obtaining a 12-lead ECG is the priority diagnostic tool to confirm a Myocardial Infarction and differentiate between STEMI and NSTEMI. The American Heart Association guidelines recommend that an ECG be performed and interpreted within 10 minutes of arrival. Oxygen should be administered if the saturation is below 94%, but the ECG is vital for determining the course of treatment. Morphine and Nitroglycerin are used for pain management but only after the diagnosis is being established. Cardiac enzymes are essential but take longer to result and do not provide the immediate data that an ECG does. Rapid reperfusion therapy depends entirely on the initial ECG findings. The nurse must remain with the client to monitor for lethal arrhythmias during this critical time. Early intervention directly correlates with the amount of heart muscle that can be salvaged.
10. A client has a chest tube connected to a water-seal drainage system. The nurse notes continuous bubbling in the water-seal chamber. What is the appropriate nursing action? A. Document this as a normal finding for a client with a pneumothorax B. Increase the suction pressure on the wall regulator C. Check the system for an air leak starting at the insertion site D. Clamp the chest tube for 4 hours to see if it stops Ans: C Rationale: Continuous bubbling in the water-seal chamber indicates a persistent air leak in the system or from the client’s lung. In a water-seal system, intermittent bubbling is normal if the client has a pneumothorax, especially during coughing or expiration. However, if the bubbling is constant, the nurse must systematically check all connections to locate the leak. The nurse should start at the insertion site and work down toward the drainage unit. Tightening connections or replacing the unit may be necessary if the leak is in the hardware. Clamping the chest tube is generally avoided unless checking for a leak, as it can cause a tension pneumothorax. The nurse should also assess the client for respiratory distress and decreased breath sounds. Prompt resolution of the leak ensures the effectiveness of the lung re- expansion process.
