ATI RN
ATI Med Surg 2 Respiratory exam Questions
Extract:
Question 1 of 5
A nurse admits a client to the emergency department who reports nausea and vomiting that worsens when he lies down. Antacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see?
Correct Answer: D
Rationale: Increased serum amylase is a hallmark of acute pancreatitis as the damaged pancreas releases more amylase into the blood.
Extract:
History and Physical
The client has a history of type 1 diabetes mellitus for 16 years, which is managed with insulin at bedtime and before each meal. The client measures capillary blood glucose twice daily. He had a motor-vehicle crash 3 years prior.
Nurses Notes
The client is lethargic and rouses with physical stimulation. His Glasgow Coma Scale score has decreased from 14 to 12. Auscultation of the lungs reveals rales in the right lower lobe. The right upper lobe is diminished but clear. Kussmaul respirations are noted. An 18-gauge IV in the right forearm is edematous and cool to touch. Capillary refill is 3 seconds. He has dry mucous membranes and decreased skin turgor.
Vital Signs
• Supine blood pressure: 100/70 mm Hg
• Sitting blood pressure: 85/50 mm Hg
• Heart rate: 120/min
• Respiratory rate: 24/min
• Temperature: 37.9°C (100.2°F)
• Oxygen saturation: 95% on room air
Medical History
The client was admitted to the unit from the emergency department. The client's partner reports lethargy, vomiting, diarrhea, and fever lasting for 2 days.
Diagnostic Results
• Casual blood glucose: 580 mg/dL (normal: <200 mg/dL)
• Sodium: 152 mEq/L (normal: 136-145 mEq/L)
• Potassium: 5.3 mEq/L (normal: 3.5-5.0 mEq/L)
• BUN: 32 mg/dL (normal: 10-20 mEq/L)
• Creatinine: 1.8 mg/dL (normal: 0.5-1.3 mg/dL)
• Serum pH: 7.2 (normal: 7.35-7.45)
• HCO3-: 13 mEq/L (normal: 21-28 mEq/L)
• Urine reagent strip testing: pH 4.4 (normal: 4.6-8.0), Specific gravity: 1.036 (normal: 1.005-1.030), Ketones: positive (negative), Glucose: present (none)
• Glycosylated hemoglobin: 9.69% (normal: <7.9% indicates good diabetic control)
ECG Findings
ECG indicates tachycardia with a prolonged PR interval, widened QRS, and peaked T waves.
Question 2 of 5
A nurse is admitting a 45-year-old male client who has type 1 diabetes mellitus in the emergency department. Select the findings that require immediate attention.
Correct Answer: A,C,F,G,H
Rationale: The Glasgow Coma Scale score decrease indicates worsening neurological status. Low bicarbonate suggests metabolic acidosis. Hypotension indicates hemodynamic instability. ECG findings suggest hyperkalemia. Hypernatremia requires prompt correction.
Extract:
Question 3 of 5
A nurse is caring for a client who has pleural effusion and has undergone thoracentesis. The nurse should identify which of the following findings as indicative of an infection?
Correct Answer: D
Rationale: Purulent fluid is indicative of an infection as it contains pus, which is a collection of dead white blood cells, bacteria, and tissue debris.
Question 4 of 5
A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan?
Correct Answer: D
Rationale: Placing the client in a prone position has been shown to improve oxygenation in ARDS by enhancing lung expansion and ventilation-perfusion matching.
Question 5 of 5
A nurse is caring for a client who has acute pancreatitis. After treating the client's pain, which of the following should the nurse address as the priority intervention?
Correct Answer: A
Rationale: Withholding oral fluids and food is the priority because it reduces pancreatic stimulation and decreases the secretion of pancreatic enzymes, preventing further autodigestion and inflammation.