ATI RN Adult Medical Surgical Exam

Correct Answer C: Absence of a bruit

Explanation of the Correct Answer:

An arteriovenous (AV) graft should produce both a bruit (a whooshing sound heard with a stethoscope) and a thrill (a vibration felt upon palpation), indicating proper blood flow. The absence of a bruit suggests that the graft may be occluded or thrombosed, which is a serious complication requiring immediate medical attention to preserve access and prevent further issues.

Why the Other Options Are Incorrect:

A. 2+ left radial pulse

A 2+ radial pulse is considered normal and does not indicate a problem with the AV graft. It reflects adequate arterial circulation distal to the graft site.

B. Dilated appearance of the AV site

A slightly dilated appearance is expected due to increased blood flow and vessel remodeling at the graft site. This alone is not indicative of a complication unless accompanied by redness, swelling, or signs of infection or clot.

D. Presence of a palpable thrill

A palpable thrill is a normal and desired finding in a functioning AV graft or fistula. It indicates adequate turbulent blood flow through the access and is regularly assessed during routine care

Correct Answer:

Absence of P waves

Explanation:

Atrial fibrillation is defined by disorganized electrical impulses in the atria, which cause the atrial muscles to quiver ineffectively rather than contract in a coordinated manner. Because of this chaotic electrical activity, the normal P waves (which represent organized atrial depolarization) disappear from the ECG. Instead, the baseline appears wavy or fibrillatory. Another classic finding in atrial fibrillation is an irregularly irregular ventricular rhythm due to the unpredictable conduction of impulses through the AV node. The absence of P waves is thus a defining diagnostic criterion.

Why the Other Options Are Wrong:

Prolonged QT interval is not associated with atrial fibrillation. A prolonged QT is more often seen in cases of certain medications, electrolyte imbalances (such as hypokalemia or hypomagnesemia), or congenital long QT syndrome. It represents delayed ventricular repolarization, which is a separate issue from atrial rhythm.

Prolonged PR interval indicates a delay in conduction between the atria and ventricles, characteristic of first-degree AV block. In atrial fibrillation, organized atrial depolarization is lost entirely, making the PR interval unmeasurable since there are no distinct P waves.

1:1 ratio of P to QRS waves is typical of a normal sinus rhythm or controlled atrial rhythm, where each atrial depolarization (P wave) is followed by a ventricular contraction (QRS complex). In atrial fibrillation, there are no true P waves and the QRS complexes occur in an irregular pattern, so this ratio does not exist.

Correct Answer A: Flush the PICC line with 0.9% sodium chloride after medication administration.

Explanation of the Correct Answer:

Flushing a PICC line with 0.9% sodium chloride after medication administration is a standard protocol to maintain catheter patency and prevent clogging. It ensures that all medication is cleared from the line and reduces the risk of drug interactions or infections. This is part of routine PICC line care.

Why the Other Options Are Incorrect:

B. Use a 3 mL syringe when flushing the PICC line.

Using a 3 mL syringe is incorrect because it generates higher pressure that can damage the catheter. A 10 mL syringe is the minimum size recommended to flush PICC lines safely and avoid rupture.

C. Expect the PICC line to be inserted into a lower extremity vein.

PICC lines are typically inserted into upper extremity veins, such as the basilic or cephalic vein, and advanced to the superior vena cava. Lower extremity insertion is not standard practice due to higher risk of complications.

D. Monitor for a pneumothorax following insertion of the PICC line.

A pneumothorax is a potential complication of central venous catheter placement in the subclavian or jugular vein, not typically of PICC lines, which are inserted peripherally. Therefore, monitoring for pneumothorax is not usually necessary after a PICC line insertion

Correct Answer D: Apnea alternating with hyperventilation

Explanation of the Correct Answer:

Apnea alternating with hyperventilation (Cheyne-Stokes respirations) is a sign of impending death and indicates significant neurologic and respiratory decline. This pattern is common in terminal stages of illness and supports the need for palliative care to ensure comfort and symptom management during end-of-life care.

Why the Other Options Are Incorrect:

A. Constipation

While common in terminally ill clients, constipation is a manageable symptom and not, by itself, a primary indicator for initiating palliative care.

B. Peripheral edema

Edema may be related to heart failure or hypoalbuminemia, but it does not by itself indicate the need for palliative care unless it significantly affects quality of life or is unmanageable.

C. Serum albumin 5.2 g/dL

This value is slightly above normal and not an indicator of declining nutritional or clinical status. Low albumin levels would be more concerning in a terminal patient.

​​​​​​Correct Answer:

Vanilla pudding

Explanation:

Vanilla pudding is the safest food choice for a client with trigeminal neuralgia because it avoids the main triggers for pain: temperature extremes, hard textures, and excessive chewing. Pudding is smooth, soft, and easily swallowed without needing to open the jaw widely or apply pressure through chewing. When served at room temperature, it also avoids stimulating the sensitive facial nerves with cold or hot temperatures. These characteristics make it an ideal dietary choice for clients at risk of triggering neuralgia flare-ups during eating.

Why the Other Options Are Wrong:

Ice cream is inappropriate because the cold temperature can provoke intense pain in clients with trigeminal neuralgia. Even though the texture is soft, the temperature itself is a powerful trigger for nerve irritation in this condition.

Vegetable soup is typically served hot, which poses another risk for triggering neuralgia pain. Like cold, hot foods can cause facial nerve stimulation. Even though the consistency may be suitable, the temperature makes it unsafe.

Graham crackers are a poor choice because they are dry, coarse, and require significant chewing. The mechanical action of chewing, especially harder or crunchier foods, can activate the trigeminal nerve and result in severe pain.

Correct Answer:

Albumin 3.1 g/dL (3.5 to 5 g/dL)

Explanation:

Albumin is a critical protein in the body that reflects nutritional status. A level of 3.1 g/dL is below the normal range (3.5 to 5 g/dL), indicating hypoalbuminemia, which is often a sign of malnutrition. Malnutrition and low albumin levels are strongly associated with poor skin integrity, delayed wound healing, and a heightened risk of pressure injuries (skin breakdown), especially in clients with limited mobility, such as those recovering from a stroke. In these patients, maintaining proper nutritional status is vital to prevent complications related to skin breakdown, which can significantly delay recovery and increase the risk of infection.

Why Other Options Are Wrong:

25-Hydroxyvitamin D 92 ng/mL (25 to 80 ng/mL)

This is incorrect because although this vitamin D level is slightly elevated, vitamin D does not directly contribute to an increased risk of skin breakdown. Vitamin D plays an important role in bone health and immune function, but it is not the primary factor affecting skin integrity. The concern in this scenario is more closely related to nutrition and protein levels, particularly albumin, rather than vitamin D.

Hgb 18 g/dL (12 to 16 g/dL)

This is incorrect because this hemoglobin level is elevated. High hemoglobin can indicate dehydration or polycythemia, but it does not directly cause an increased risk of skin breakdown. While low hemoglobin (anemia) could potentially impair oxygen delivery to tissues, which can affect healing, elevated hemoglobin is not a concern in this scenario.

WBC 12,000/mm3 (5,000 to 10,000/mm3)

This is incorrect because an elevated white blood cell count (WBC) suggests an infection or inflammation, but it does not directly indicate an increased risk of skin breakdown. While infection can affect healing and skin integrity, the key factor here is the client’s nutritional status, as indicated by the albumin level. Low albumin is a more significant risk factor for pressure injuries than a slightly elevated WBC.

Correct Answer:

S3 heart sound

Explanation:

An S3 heart sound, also known as a ventricular gallop, is often a key clinical sign of fluid volume overload. It occurs when there is excessive fluid in the circulatory system, leading to increased ventricular filling. The extra volume causes turbulence, producing the distinct low-pitched sound during early diastole. In patients receiving total parenteral nutrition (TPN), which is rich in both fluid and dextrose, fluid overload is a significant risk, particularly if the infusion rate is too fast or if the patient has compromised cardiac or renal function. The nurse should also monitor for other symptoms of fluid overload, such as edema, crackles in the lungs, weight gain, and hypertension, which may accompany the S3 heart sound in such patients.

Why Other Options Are Wrong:

+1 pedal pulses

+1 pedal pulses indicate weak, diminished pulses, which are not typically associated with fluid overload. Fluid overload often causes bounding pulses (+3 or +4) due to the increased circulatory volume. Weak pulses, on the other hand, are more commonly seen with hypovolemia or poor perfusion, not fluid excess. Therefore, this finding does not support the diagnosis of fluid overload.

Urinary output of 20 mL in the past hour

A urinary output of 20 mL in the past hour suggests oliguria, a condition where urine output is abnormally low. Oliguria is more indicative of fluid deficit, dehydration, or potential kidney dysfunction rather than fluid overload. In cases of fluid overload, the kidneys may increase urine output to help compensate, provided they are functioning adequately. Therefore, low urine output would not align with fluid volume excess.

Temperature of 38° C (100.4° F)

A temperature of 38° C (100.4° F) indicates a mild fever, which could suggest an infection, often associated with TPN due to the risk of central line-associated infections. However, a fever is not related to fluid overload, which does not cause changes in body temperature. Therefore, the presence of a fever would be more indicative of an infection rather than fluid excess.

Correct Answer:

Monitor for bleeding on the surgical dressing

Explanation:

Following a splenectomy, the most critical concern is postoperative hemorrhage. The spleen is a highly vascular organ, and its removal places the client at significant risk for both internal and external bleeding. Monitoring the surgical dressing for signs of bleeding—such as saturation, rapid accumulation, or expansion of the hematoma—is an essential and immediate nursing priority. This intervention aligns with the ABCs (Airway, Breathing, Circulation), specifically the "C" for circulation, as uncontrolled bleeding can rapidly lead to hypovolemic shock and death if not identified and managed promptly.

Why Other Options Are Wrong:

Check the client's cardiac rhythm

This is incorrect because dysrhythmias are not a common or direct complication following a splenectomy. While cardiac monitoring is a routine part of postoperative care, it is not the priority in this specific situation unless the client has a pre-existing cardiac condition or shows signs of hemodynamic instability due to bleeding.

Check the client's level of consciousness

This is incorrect. Although changes in level of consciousness can be an indicator of poor perfusion or shock, it is a late finding. Prioritizing assessment of the dressing for bleeding allows for earlier intervention. Waiting for neurological symptoms could mean the client has already progressed into more advanced circulatory compromise.

Monitor the client's oxygen saturation

This is incorrect. While oxygen saturation monitoring is important after surgery, it is not the most immediate concern in the case of a splenectomy. Hemorrhage precedes oxygenation issues; therefore, addressing bleeding is the first step. Without adequate circulating volume, oxygen delivery to tissues will be compromised regardless of oxygen saturation readings.

Correct Answer:

Atrial fibrillation

Explanation:

Synchronized cardioversion is indicated for clients with tachyarrhythmias who are hemodynamically unstable but have a pulse. Atrial fibrillation is one such rhythm where the atria beat rapidly and irregularly, leading to reduced cardiac output. In cases where AFib causes significant symptoms like hypotension, chest pain, or shortness of breath and does not respond to medication, synchronized cardioversion can be used to restore normal sinus rhythm. The "synchronized" aspect means the electrical shock is timed to coincide with the R wave of the QRS complex to avoid the vulnerable repolarization period (T wave), thereby minimizing the risk of inducing more dangerous rhythms like ventricular fibrillation.

Why Other Options Are Wrong:

Ventricular fibrillation

This is incorrect because ventricular fibrillation is a pulseless, chaotic rhythm requiring immediate defibrillation, not synchronized cardioversion. Since there are no organized electrical impulses or recognizable R waves in VFib, synchronization cannot be performed. Instead, high-energy unsynchronized shocks (defibrillation) are required immediately to attempt to restore a perfusing rhythm. Synchronized cardioversion in this context would delay life-saving treatment and is inappropriate.

Asystole

This is incorrect because asystole is a complete absence of cardiac electrical activity, often referred to as "flatline." Electrical shocks are ineffective in this situation because there is no rhythm to reset. The appropriate treatment includes high-quality CPR and administration of epinephrine. Both defibrillation and synchronized cardioversion are contraindicated and ineffective in asystole.

Pulseless ventricular tachycardia

This is incorrect because pulseless ventricular tachycardia is a life-threatening rhythm that, like ventricular fibrillation, requires immediate unsynchronized defibrillation. Synchronized cardioversion is used only when VTach presents with a pulse. In the absence of a pulse, every second counts, and defibrillation is the definitive intervention to restore an organized rhythm. Using synchronized cardioversion in this context would be inappropriate and dangerously delay correct treatment.