ATI RN
ATI Med Surg Pharm Comprehensive Exam 1 Questions
Question 1 of 5
A nurse is caring for a client who has metastatic bone cancer. The client states, 'I want to go home to die.' The family is concerned about meeting the client's care needs at home. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Discussing initiating hospice care is appropriate to address the client's desire to go home for end-of-life care and to provide support and resources for the family.
Extract:
Vital Signs
1200:
Temperature 38.6° C (10.5° F)
Heart rate 109/min
Respiratory rate 28/min
Blood pressure 106/54 mm Hg
Oxygen saturation 94% on room air
Nurses' Notes
Client presents to ED with report of shortness of breath for 2 days, with headache, chills, fever, sore throat, and cough. States they went to a music concert recently "and probably picked up some kind of virus." Oriented to person, place, and time. Appears lethargic, difficulty answering questioning due to shortness of breath. Follows simple commands, moves all extremities with weakness.
Client's face is flushed, sinus tachycardia, rate of 109/min, S152 heart sounds heard on auscultation. Pulses palpable.
Breath sounds with crackles to right lower lobe, tachypnea, rate of 28/min. Frequent productive cough with thick yellow sputum. Client denies hemoptysis. Unable to lie down, states they are "more comfortable sitting up."
Bowel sounds active x 4 quadrants. Denies diarrhea, last bowel movement yesterday. States "no appetite since I've been sick."
Reports decreased urination over past 24 hr. "Haven't been drinking as much water as I should because my throat hurts."
Client reports they have not had a pneumococcal vaccine and does not get annual influenza vaccinations. States, "I just hate needles."
Diagnostic Results
1230:
Chest x-ray:
Areas of increased density and white infiltrates to lower right lobe indicative of pneumonia
Medical History
1215:
70 years of age
No significant medical history other than primary concern
Well nourished
Home Medications:
Daily multi-vitamin
Vitamin D
Social History.
Lives alone, partner died 5 years ago
Drinks 1 to 2 glasses of red wine daily
Has never smoked
Walks 2 to 3 miles 6 days/week
Question 2 of 5
Select 4 findings in the client's medical record that place them at risk for pneumonia.
Correct Answer: A,C,E,F
Rationale: The client has not received pneumococcal vaccine, which increases susceptibility to pneumococcal pneumonia. The client has not received influenza vaccine, which increases susceptibility to influenza-related pneumonia. The client's fluid intake seems to be reduced, as indicated by their decreased urination and reports of not drinking much water due to a sore throat, which can contribute to the risk of infection. Being 70 years old increases susceptibility to respiratory infections like pneumonia.
Extract:
Question 3 of 5
A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse?
Correct Answer: D
Rationale: Palpating the abdomen prior to auscultation can alter bowel sounds, making it important to auscultate before palpation.
Question 4 of 5
An older adult client is scheduled to have an elective surgical procedure and informs the nurse that she wants to be designated as a 'do not resuscitate' (DNR) case. Which of the following responses should the nurse provide?
Correct Answer: D
Rationale: The provider should directly discuss the client's wishes regarding a DNR order to ensure understanding and documentation.
Question 5 of 5
A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: Measuring the circumference of both upper arms is the first action to assess the extent of the swelling and compare it to the other arm, which will help determine the severity of the issue.