ATI RN
ATI SP 250 Exam 3 Med Surg Exam Questions
Extract:
Question 1 of 5
A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?
Correct Answer: C
Rationale: This is because central cyanosis reflects a decrease in arterial oxygen saturation and is best seen in areas where blood vessels are close to the surface, such as the oral mucosa, tongue, and lips. Peripheral cyanosis, which may be caused by vasoconstriction or poor circulation, can be seen in the soles of the feet, ear lobes, and nail beds, but it does not necessarily indicate hypoxemia.
Question 2 of 5
A nurse in a community health clinic is administering seasonal inactive influenza vaccine. Before administering it, the nurse must confirm that the client is not allergic to which of the following?
Correct Answer: C
Rationale: This is because some influenza vaccines are prepared using chicken eggs and may contain trace amounts of egg protein, which can cause an allergic reaction in some people.
Question 3 of 5
A nurse is caring for a client who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications?
Correct Answer: A,C,D
Rationale: These interventions can help prevent complications such as stress ulcers, ventilator-associated pneumonia, and aspiration. Pantoprazole reduces gastric acid secretion and protects the mucosa from erosion. Verifying the ventilator settings ensures that the client is receiving adequate oxygenation and ventilation according to their needs and goals. Elevating the head of the bed reduces the risk of aspiration and improves lung expansion.
Question 4 of 5
A nurse is talking with a client who has to come to the clinic for HIV testing. The nurse should explain that, after the laboratory has the enzyme-linked immunosorbent assay (ELISA) results, it will use which of the following tests to confirm the diagnosis?
Correct Answer: B
Rationale: This is because Western blot analysis detects specific antibodies to HIV antigens and has a high specificity and sensitivity for HIV infection. CD4+ T-cell count, quantitative RNA assay, and viral load test do not confirm the diagnosis but provide additional information about the disease progression.
Extract:
Nurses' Notes
Day 1:
0900:
Client admitted from emergency department with hemoptysis, dull chest pain, increasing fatigue, anorexia, nausea, chest tightness, and 3.2 kg (7 Ib) weight loss in 2 weeks. Heart rate regular, lung sounds with crackles in bilateral upper lobes. No edema. Airborne precautions initiated upon admission.
Day 2:
Client reports shortness of breath, nausea, and fatigue. Crackles auscultated bilaterally throughout lung fields. Productive cough, with thick, blood-streaked sputum. Bowel sounds active, no edema.
Question 5 of 5
A nurse on a medical-surgical unit is caring for a newly admitted client with a diagnosis of R/O tuberculosis. Which of the following findings should the nurse report to the provider?
Correct Answer: A
Rationale: This is because tuberculosis can affect the liver and cause hepatotoxicity, especially if the client is taking anti-tuberculosis medications. The nurse should monitor the client's liver function tests, such as AST and ALT levels, and observe for signs of liver damage, such as yellow sclera, dark urine, clay-colored stools, and abdominal pain.