ATI RN
ATI Medical Surgical 2 Final 2024 Assessment Questions
Extract:
Question 1 of 5
A nurse is assessing a client who has intravenous therapy-related phlebitis. The nurse uses the Infusion Nurses Society's phlebitis scale to assess the severity of phlebitis and documents the client's phlebitis as grade level 1. Which of the following assessment findings correlates with a grade level of 1?
Correct Answer: B
Rationale: Redness at the IV site with pain corresponds to grade 1 phlebitis on the Infusion Nurses Society's scale, indicating mild erythema and possible pain. Purulent drainage, red streaks, and a palpable venous cord indicate more severe grades (2-4).
Question 2 of 5
A nurse is caring for a client who is receiving cisplatin for the treatment of ovarian cancer. The client's most recent complete blood count (CBC) is shown in the table below. It is important for the nurse to consider which of the following for the client?
Correct Answer: C
Rationale: The client's WBC count of 1,400/mm^3 indicates leukopenia, significantly increasing infection risk. Hemoglobin (12.1 g/dL) and albumin (4.5 g/dL) are normal, so erythropoiesis-stimulating agents or increased protein diet are not indicated. Platelet count (170,000/mm^3) is normal, so bleeding risk is not elevated.
Question 3 of 5
A nurse is assessing the reflexes of a client who has an unrepaired femur fracture and has suddenly become stuporous. For which of the following findings should the nurse identify that the client exhibits Babinski's sign?
Correct Answer: A
Rationale: A positive Babinski's sign in adults, indicated by dorsiflexion of the great toe, suggests neurological dysfunction, possibly from a complication like fat embolism.
Question 4 of 5
A nurse is assessing a client who is being admitted from the Post-Anesthesia Care Unit (PACU) following an abdominal hysterectomy. Which of the following assessments is the nurse's priority?
Correct Answer: B
Rationale: Oxygen saturation is the priority to ensure adequate oxygenation post-anesthesia, preventing respiratory complications.
Question 5 of 5
A nurse is caring for a client who has fibrocystic breasts. The client asks the nurse, 'What will happen to my fibrocystic breast changes after menopause?' Which of the following statements is an appropriate response by the nurse?
Correct Answer: D
Rationale: The most appropriate response is that the manifestations usually go away after menopause. Fibrocystic breast changes are linked to hormonal fluctuations, and after menopause, when these fluctuations cease, the symptoms of fibrocystic breasts typically resolve.