ATI RN
ATI 410 Med Surg Exam Questions
Extract:
Question 1 of 5
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)
Correct Answer: A,C,E
Rationale: Tachycardia occurs as the heart compensates for increased blood volume. Hypertension results from increased vascular resistance due to excess fluid. Increased respiratory rate is due to pulmonary congestion from fluid overload. Hematocrit decreases due to dilution, and temperature is not directly affected.
Question 2 of 5
A nurse is providing teaching to a client who has a prescription for heat therapy for treatment of cellulitis of the right lower leg. Which of the following client statements indicates an understanding of the teaching?
Correct Answer: C
Rationale: A warm, wet towel provides moist heat, promoting blood flow and healing in cellulitis without risking burns or uneven heating from other methods.
Question 3 of 5
A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for clients who have surgical incisions. Which of the following factors should the nurse include in the teaching? (Select all that apply.)
Correct Answer: B,C,D
Rationale: Poor nutrition weakens tissue strength, infection compromises wound integrity, and obesity increases pressure on the wound, all raising dehiscence risk. Pain medication and altered mental status do not directly contribute.
Question 4 of 5
A nurse is teaching a group of clients about the specific types of fluids that protect the structures of the inner ear. Which of the following statements should the nurse include in the teaching?
Correct Answer: A
Rationale: Endolymph is found within the inner ear, specifically in the membranous labyrinth, and plays a crucial role in hearing and balance. Sanguineous fluid refers to blood or fluid containing blood and is not present in the inner ear. Aqueous humor and vitreous humor are fluids found in the eye, not the ear.
Extract:
Nurse's Notes:
Client admitted to the unit for a lower GI bleed. Continues to have frequent bloody stools and is scheduled for a lower endoscopy in 4 hr. The client is receiving their fourth unit of packed red blood cells (packed RBCs). Unit of fourth packed RBCs started at a rate of 250 cc/hr. Thirty minutes after the transfusion started, the client started reporting dyspnea and restlessness. Crackles auscultated in bilateral lower lobes. oxygen saturation 92% on 2L nasal cannula, and jugular vein distention noted.
Vital signs:
Temperature: 37.0°C (98.6°F)
Heart Rate (HR): 110 beats per minute
Blood Pressure (BP): 150/90 mmHg
Respiratory Rate (RR): 24 breaths per minute
Oxygen Saturation (SpO2): 92% on 2L nasal cannula
Question 5 of 5
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
Correct Answer: B,C,D
Rationale: The client is experiencing transfusion-associated circulatory overload (TACO), indicated by dyspnea, crackles, jugular vein distention, and hypertension. Stopping the transfusion prevents further fluid overload, and furosemide removes excess fluid. Monitoring weight and respiratory rate assesses fluid status and respiratory distress.