ATI RN
ATI Nur258 Med Surg 2 Final Exam Questions
Extract:
Question 1 of 5
A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis. Which finding should the nurse expect?
Correct Answer: A
Rationale: Clay-colored stools are indicative of a bile duct obstruction because bile is not reaching the intestines, leading to pale or clay-colored stools.
Question 2 of 5
A nurse is preparing to administer cefazolin 1 g by intermittent intravenous (IV) bolus over 30 minutes. Available is cefazolin 1 g in 100 mL dextrose 5% in water (D5W). The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero. Only enter numbers and decimals. Do not enter any letters in your answer.)
Correct Answer: 33
Rationale: Infusion rate = 3.33 mL/min x 10 gtt/mL = 33.3 gtt/min, rounded to 33 gtt/min.
Extract:
Medical History
Client admitted with report of polyuria and polydipsia.
Notable muscle twitching of upper extremities.
Past medical history: Varicella as a child. No other health issues.
Current medications: Occasional ibuprofen for pain.
Family history: Father had history of nephrogenic diabetes insipidus.
Physical Examination
Alert and oriented to person, place, and time.
Client states that they have had difficulty concentrating lately and are irritable.
Client reports occasional dizziness.
Skin is warm, dry, and scaly.
Mucous membranes dry and pink.
Lungs clear to auscultation bilaterally.
Abdomen soft, nondistended with active bowel sounds x 4.
Denies nausea, vomiting, or diarrhea.
Peripheral pulses 1+
Twitching noted in upper extremities, client states they have had twitching "for some time."
Nurses' Notes
0845:
Needed assistance to the bathroom, reports dizziness.
Urine output 1,500 mL.
Assisted client to bed.
Vitals taken.
Vital Signs
0800:
Temperature 37.4° C (99.4° F)
Heart rate 100/min
Respiratory rate 22/min
Blood pressure 108/78 mm Hg
SpO2 98% on room air
0900:
Temperature 37.4° C (99.4° F)
Heart rate 104/min
Respiratory rate 22/min
Blood pressure 96/70 mm Hg
Diagnostic Results
Basic metabolic profile
Sodium 157 mEq/L (nl. 136-145 mEq/L)
Potassium 3.49 mEq/L (nl. 3.5-5 mEq/L)
Chloride 102 mEq/L (nl. 98-106 mEq/L)
Magnesium 1.8 mEq/L (nl. 1.8-2.6 mEq/L)
Total calcium 9.7 mg/dL (nl. 8.8-10.4 mg/dL)
Complete blood count (CBC) with differential
Total white blood cell (WBC) count 6,500/mm3 (nl. 5,000-10,000/mm3)
Neutrophils 60% (55% to 70%)
Lymphocytes 30% (20% to 40%)
Monocytes 5% (2% to 8%)
Eosinophils 2.5% (1% to 4%)
Basophils 0.7% (0.5% to 1%)
Hemoglobin 21 g/dL (Male: 14 to 18 g/dL; Female: 12 to 16 g/dL)
Hematocrit 55% (Male: 42% to 52%; Female: 37% to 47%)
RBCs 5.7 x 106µL (Male: 4.7 to 6.1 x 106µL; Female: 4.2 to 5.4 x 106µL
Question 3 of 5
Complete the following sentence by using the lists of options. The nurse should first address the client's..... followed by the client's.....
Correct Answer: A,B
Rationale: Elevated sodium level (157 mEq/L) indicates hypernatremia, requiring urgent correction. Blood pressure should be addressed next to ensure stability.
Extract:
Question 4 of 5
A nurse is planning care for a client who has leukemia and a platelet count of 60,000/mm³ (nl. 140,000-400,000/mm³). Which intervention should the nurse include in the plan of care?
Correct Answer: B
Rationale: Administering stool softeners is a key intervention for clients with thrombocytopenia, as it helps to prevent straining during bowel movements, which could cause rectal bleeding due to fragile blood vessels.
Extract:
Nurses Notes
2100
Client arrives to ED with family who report client had been recovering well after a motor vehicle crash 2 weeks ago in which the client sustained an open head injury. Family members report that the client has become increasingly irritable over the last 2 days and has reported a headache since this morning. Family members report that as of this evening the client developed a fever and began throwing up.
2130:
Healthcare provider notified of assessment findings. Prescriptions received.
2200:
Lumbar puncture performed by healthcare provider using sterile technique. Tolerated well by client. Cerebral spinal fluid specimen labeled
Physical Examination
2115:
Awake, but drowsy. Oriented to person, place, and time. Client currently has a headache, reports pain as 8 on a scale of 0 to 10. Pupils are equal, round, and reactive to light. Client withdraws during pupil assessment verbalizing that the light is too bright and hurts their eyes. Unable to perform full range of motion of the neck due to nuchal rigidity. Kernig sign positive. Client is irritable and easily agitated during physical assessment.
Vital Signs
2105:
Temperature 38.9° C (102° F)
Heart rate 100/min
Respiratory rate 20/min
Blood pressure 129/79 mm Hg
SpO2 97% on room air
Healthcare Provider's Prescriptions
2145:
Computed tomography (CT) scan
Prepare for lumbar puncture
Cerebrospinal fluid analysis
Diagnostic Results
2330:
Cerebrospinal fluid (CSF) analysis
White blood cell (WBC) count 300 cells/microliter (nl. 0-10 cells/microliter)
Neutrophils 50% (nl. 0-6%)
Protein 85 mg/dL (nl. 15-45 mg/dL)
Glucose 40 mg/dL (nl. 50-75 mg/dL)
Color: Turbid (nl. clear and colorless)
Culture and sensitivity: Pending
Pressure 25 cm H2O (nl. less than 20 cm H20)
Question 5 of 5
The nurse should determine the assessment findings are consistent with which of the following disease processes? For each assessment finding, click to specify if the finding is consistent with bacterial meningitis or encephalitis. Each finding may support more than 1 disease process.
| Options | Bacterial Meningitis | Encephalitis |
|---|---|---|
| WBC count in CSF | ||
| Muscle weakness | ||
| Altered level of consciousness | ||
| Kernig sign result | ||
| Body temperature at 2105 |
Correct Answer: A,C,D,E
Rationale: A high WBC count in CSF is associated with bacterial meningitis. Muscle weakness and altered consciousness are prominent in encephalitis. Kernig sign supports bacterial meningitis. Elevated temperature is common in both.