ATI RN
ATI Advanced Med Surg Exam 4 Questions
Extract:
Question 1 of 5
A nurse in an emergency department is assessing a client who was bitten on the left leg by a poisonous snake. The client has placed elastic bandages snuggly above and below the bite marks and is in no apparent distress. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: Obtaining anti-venom is critical to prevent systemic effects of venom.
Extract:
Vital Signs
Blood pressure 180/90 mm Hg
Heart rate 105/min
Temperature 37.1° C (98.8 F)
Respirations 18min; labored
Pulse oximetry 94 on 2L nasal cannula
Medical History
History of coronary artery disease
Type 2 diabetes mellitus
Renal failure
Renal transplant 6 weeks ago
Nurses Notes
The client reports worsening fatigue over the last 3 days. The client also reports loss of appetite, denies nausea or vomiting.
On assessment, the client appears pale, lung and heart sounds within defined limits. Abdomen is tender in area of incision from transplant Bowel sounds are hypoactive in all 4 quadrants. Bilateral pedal pulses +2. +1 edema in bilateral lower extremities. Client reports that for the last 2 days they have only urinated twice per 24-hour period.
Diagnostic Results
BUN 25 mg/dL (10 to 20 mg/dL)
Creatine 2.0 mg/dL (0.5 to 1.3 mg/dL)
Hemoglobin 15 mmol/L (12 to 18 mmol/L)
Hematocrit 45% (37% to 52%)
Potassium 5.2 mEq/L (3.5 to 5.0 mEq/L)
Sodium 145 mEq/L (136 to 145 mEq/L)
Question 2 of 5
A nurse is caring for a client who is admitted to the emergency department for fatigue. Which of the following findings indicate that the client may be experiencing transplant rejection? (Select all that apply).
Correct Answer: A,B,E,F
Rationale: A: Incision tenderness indicates inflammation. B: Edema suggests kidney issues. E: High creatinine indicates rejection. F: Hypoactive bowels may indicate reduced perfusion.
Extract:
Question 3 of 5
A patient arrives in the emergency department (ED) several hours after taking "25 to 30" acetaminophen (Tylenol) tablets. Which action will the nurse plan to take?
Correct Answer: C
Rationale: N-acetylcysteine prevents liver damage in acetaminophen overdose.
Question 4 of 5
During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient has an unobstructed airway. Which action should the nurse take next?
Correct Answer: D
Rationale: Observing respiratory effort ensures adequate breathing in the primary survey.
Question 5 of 5
A nurse is providing teaching to a client who has neutropenia. Which of the following information should the nurse include in the teaching?
Correct Answer: A
Rationale: Neutropenic clients must avoid crowds to minimize infection exposure.