ATI RN Adult Medical Surgical 2023 III

Extract:

Question 1 of 5

A charge nurse receives a call from the house supervisor requesting room assignments for four new clients. Based on the admission diagnoses, which of the following clients requires a private room?

A. A client who has a compound fracture of the right femurB. A client who reports having fever, night sweats, and cough for 2 daysC. An older adult client who was admitted with aspiration pneumoniaD. A client who has diabetes mellitus and is presenting with acute ketoacidosis

Correct Answer: B

Rationale: Fever, night sweats, and cough suggest possible tuberculosis, requiring a private room for airborne precautions.

Question 2 of 5

A nurse is providing teaching for a client who has diabetes mellitus about the self-administration of insulin. The client has prescriptions for regular and NPH insulins. Which of the following statements by the client indicates an understanding of the teaching?

A. I will insert the needle at a 15-degree angle.B. I will store prefilled syringes in the refrigerator with the needle pointed downward.C. I will shake the NPH vial vigorously before drawing up the insulin.D. I will draw up the regular insulin into the syringe first.

Correct Answer: D

Rationale: Drawing up regular insulin before NPH prevents contamination of the regular insulin with NPH, ensuring accurate dosing.

Extract:

Nurses' Notes
Day 1:

1000:

Client is alert to person, place, and time. Client is short of breath and leans forward to breathe easier. Lung sounds are diminished in bilateral bases with occasional wheezes. Nonproductive cough. Heart rate is regular. +2 pulses in all extremities.

1500:

Client is tachypneic, cough is productive, and mucous is yellow in color. Wheezes and crackles heard upon auscultation. Heart rate is regular. +2 pulses in all extremities. Client is oriented to person, place and time. Client is restless. Pupils are reactive to light. Client is diaphoretic with cyanotic mucous membranes

Vital Signs
1000:

Temperature: 37.1°C (98.8°F)
Heart Rate: 100/min
Respiratory Rate: 22/min (irregular)
Blood Pressure: 164/80 mm Hg
Oxygen Saturation: 92% on room air
1500:

Temperature: 37.3°C (100.3°F)
Heart Rate: 110/min
Respiratory Rate: 26/min (irregular)
Blood Pressure: 110/58 mm Hg
Oxygen Saturation: 87% on room air

Question 3 of 5

A nurse is caring for a client who has COPD. Select the findings below that require immediate follow-up.

A. pulses in all extremities.B. Client is restlessC. tachypneic, cough is productiveD. Client is oriented to person, place, and timeE. mucous is yellowF. Wheezes and crackles

Correct Answer: B,C,E,F

Rationale: Restlessness, tachypnea, yellow mucous, and wheezes/crackles indicate worsening COPD requiring intervention.

Extract:

Medical History
Conditions:
• Dehydration
• Hyperlipidemia
• Hypertension
• Coronary artery disease (CAD)

Diagnostic Results

• WBC Count: 14,000/mm³ (Normal: 5,000 to 10,000/mm³)
• Hemoglobin (Hgb): 14 g/dL (Normal: 12 to 16 g/dL)
• Hematocrit (Hct): 40% (Normal: 34 to 47%)
• Sodium: 132 mEq/L (Normal: 136 to 146 mEq/L)
• Potassium: 6.2 mEq/L (Normal: 3.5 to 5 mEq/L)
• Calcium: 10 mg/dL (Normal: 9 to 10.5 mg/dL)
• BUN: 20 mg/dL (Normal: 10 to 20 mg/dL)
• Albumin: 2.8 g/dL (Normal: 3.5 to 5 g/dL)
• Fasting Blood Glucose: 140 mg/dL (Normal: 74 to 106 mg/dL)
• Triglycerides: 134 mg/dL (Normal: 34 to 160 mg/dL)

Nurses' Notes
Client is lying in bed. Awake, alert, and oriented to time, place, and person. Client is febrile and reports weakness. Receiving TPN via central line in left antecubital. Client is NPO and has had diarrhea x3 in past 4 hr. Crackles auscultated in posterior lobes.

Client has a productive cough and sputum is yellow in color. Client receiving 2 L/min oxygen via nasal cannula with an oxygen saturation of 90%. Abdomen is distended and tender. Active range of motion to all extremities. Denies pain at this time.

Question 4 of 5

Which of the following actions should the nurse take? For each potential nursing intervention, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client.

Options	Anticipated	Nonessential	Contraindicated
Obtain client weight twice daily.
Have 3 nurses verify the TPN solution prescription.
Request a prescription for insulin.
Request an antibiotic to be administered.
Decrease the client's oxygen to 1.5 L/min oxygen via nasal cannula.
Notify provider to increase TPN rate/hr.

Correct Answer: (See rationale)

Rationale: Weight monitoring and insulin are anticipated for CAD and dehydration; TPN verification is nonessential; antibiotics and oxygen reduction are contraindicated without indication.

Extract:

Question 5 of 5

A nurse is caring for a client immediately following a cardiac catheterization through the right femoral artery. Which of the following actions should the nurse take?

A. Monitor the client's vital signs once every hour.B. Elevate the head of the client's bed to a 45Â° angle.C. Restrict the client's fluid intake.D. Instruct the client not to bend the affected leg.

Correct Answer: D

Rationale: Keeping the affected leg straight prevents bleeding or hematoma formation at the catheterization site.

ATI RN Adult Medical Surgical 2023 III | Nurselytic

Nurselytic

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