ATI RN
ATI Advanced Med Surg Final Exam 0924 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: B,C,E
Rationale: Increased respiratory rate can occur as the body tries to compensate for fluid overload, which may affect lung function and cause respiratory distress. Increased blood pressure is a common finding in fluid overload due to increased blood volume in the circulatory system. Increased heart rate can occur as the body compensates for increased blood volume and higher blood pressure.
Question 2 of 5
A nurse is caring for a client who is postoperative following an open reduction internal fixation (ORIF) of a femur fracture. Which of the following parameters should the nurse include in the evaluation of the neurovascular status of the client's affected extremity? (Select all that apply.)
Correct Answer: B,C,D,E
Rationale: Skin integrity, temperature, color, and sensation are all critical parameters for assessing neurovascular status to detect complications like impaired circulation or nerve damage.
Extract:
Medical History
Day 1:
Client has a history of emphysema and reports smoking 21 packs of cigarettes per year.
Vital Signs
Day 1:
Temperature 37.6° C (99.7° F)
Blood pressure 114/56 mm Hg
Heart rate 78/min
Respiratory rate 20/min
Pulse oximetry 93% on room air
Day 2:
1000
Temperature 36.9° C (98.4° F)
Blood pressure 88/56 mm Hg
Heart rate 118/min
Respiratory rate 32/min
Pulse oximetry 85% on room air
Diagnostic Results
Day 1:
Chest x-ray shows lung hyperinflation.
Day 2
1000:
Chest x-ray shows right upper lobe pneumothorax.
Nurses' Notes
Day 2:
0800:
Voided 350 mL of clear yellow urine in a bedpan.
1000:
Client reports sudden, sharp, right upper chest pain.
Client appears anxious and states pain increases with deep breathing.
Respirations labored with use of accessory muscles noted.
Crepitus palpated on right upper chest.
Trachea midline, breath sounds decreased in right upper lobe.
Question 3 of 5
For each potential nursing action, click to specify if the action is essential, non-essential, or contraindicated for the client.
| Action | essential | non-essential | contraindicated |
|---|---|---|---|
| Administer an analgesic | |||
| Initiate a weight-based continuous heparin infusion | |||
| Initiate supplemental oxygen | |||
| Prepare client for a chest tube insertion | |||
| Insert an indwelling urinary catheter |
Correct Answer: A,C,D
Rationale: Administer an analgesic is essential for pain management. Initiate supplemental oxygen is essential due to low pulse oximetry. Prepare client for a chest tube insertion is essential to treat the pneumothorax.
Extract:
Question 4 of 5
A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Performing pre-oxygenation prior to suctioning can help prevent hypoxia and subsequent cardiac arrhythmias caused by the suctioning procedure.
Extract:
Physical Examination
0800:
Alert and oriented to person and place
Skin pale and dry
Pupils equal, round, and reactive to light and accommodation Mucous
membranes moist and pink
Heart sounds regular and moderate
Peripheral pulses moderate
Capillary refill 3 seconds
Lungs sounds clear to auscultation bilaterally
Respirations labored at rest
Abdomen soft and nontender, active bowel sounds x 4 quadrants
No peripheral edema
Reports slight midsternal chest pain, rates pain as a 2 on a 0 to 10 pain scale
States they have been weak for the past 4 months with dizziness. Denies dizziness at this time.
1300
Returns to room after insertion of permanent pacemaker Alert and oriented to person, needs cues for time and place
Skin cool and dry
Heart sounds regular, heart rate 72/min
Lung sounds are coarse bilaterally
Hyperresonance noted upon percussion of chest wall
Respiratory rate 24/min and slightly labored
Oxygen saturation 2 U/min per nasal cannula 98%
Reports slight incisional pain left upper chest area
Small amount red drainage present on dressing over incisional site
Diagnostic Results
RBC count 5.2 million/mm3 (4.7 to 6.1 million/mm3) WBC count 7,000 mm (5,000 to 10,000 mm3)
Hemoglobin 15.4 g/dL (14 to 18 g/dL)
Hematocrit 48% (42% to 52%)
Platelets 250,000/mm3 (150,000 to 400,000/mm3)
Basic Metabolic Profile:
BUN 18 mg/dL (10 to 20 mg/dL)
Creatinine 1.0 mg/dL (0.6 to 1.3 mg/dL)
Total Calcium 9.5 mg/dL (9.0 to 10.5 mg/dL)
Carbon Dioxide 27 mEq/L (23 to 30 mEq/L) Chloride 101 mEq/L (98 to 106 mEq/L) Glucose 80 mg/dL (74 to 106 mg/dL) Potassium 5.1 mEq/L (3.5 to 5 mEq/L) Sodium 140 mEq/L (136 to 145 mEq/L)
Vital Signs
Temperature 36 Cm
Apical pulse 42min
Respiratory rate 25/min
Blood pressure 106/58 mm Hg
Oxygen saturation 54% on room air
Question 5 of 5
The nurse is caring for the client immediately following the insertion of the permanent pacemaker.Complete the following sentence by using the list of options. The nurse should monitor the client for __ and __ following permanent pacemaker placement.
Correct Answer: A,B
Rationale: Monitoring for incisional site bleeding ensures no complications like hematoma. Bradycardia monitoring ensures the pacemaker is functioning correctly.