ATI RN
ATI SP 250 Exam 3 Med Surg Exam Questions
Extract:
Question 1 of 5
A nurse is assessing a client who has pulmonary tuberculosis. Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: This is because pulmonary tuberculosis causes inflammation and damage to the lungs, which reduces oxygen exchange and leads to fatigue and weakness.
Question 2 of 5
A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines the nurse should document burns to which percentage of the client's total body surface area (TBSA)?
Correct Answer: D
Rationale: This is because according to the rule of nines, each arm accounts for 9 percent and each leg accounts for 18 percent of the TBSA.
Therefore, burns on both arms and both legs equal (9+9+18+18) = 54%.
Extract:
Nurses' Notes
Vital Signs
Medication
Home health nurse admission note:
Client discharged from healthcare facility yesterday following a 4-day stay for exacerbation of COPD. Lives alone; alert and oriented to person, place, and time. Lung fields with scattered rhonchi throughout, cough productive for thick white sputum, dyspnea with minimal exertion.
Clubbing is noted on fingers, chest is barrel-shaped. Supplemental oxygen at 2L/min via nasal cannula.
Home Health Nurse Note 3 days following discharge from health care facility: Client sleeping in recliner with nasal canula on their lap; awakens easily and is oriented to person but disoriented to place and time.
Lung sounds with scattered rhonchi, cough productive for thick, yellow secretions. 2+pitting edema bilateral in ankles and feet.
Re-oriented client. Client states "I don't remember if I did that breathing machine thing you told me about."
Instructed client on oxygen use, safety, and nebulizer treatments. Elevated lower extremities.
Question 3 of 5
A nurse is caring for a client who has COPD. Select the 5 findings that require follow-up.
Correct Answer: A,C,D,E,F
Rationale: Disorientation may indicate hypoxia, infection, or medication side effects. Yellow sputum may indicate a bacterial infection that requires antibiotics. Nebulizer use may indicate that the client is not using it correctly or regularly as prescribed, which can affect their lung function and oxygenation. Ankle edema may indicate fluid overload or heart failure, which can worsen COPD symptoms and increase the risk of complications. Living alone may pose safety risks for the client, especially if they are disoriented or have difficulty managing their oxygen and nebulizer treatments.
Extract:
Vital Signs
• Temperature 38.1° C (100.6° F)
• Heart rate 122/min
• Respiratory rate 26/min
• BP 136/85 mm Hg
• Oxygen saturation 93% on room air
Question 4 of 5
A nurse is caring for a client who has HIV. The client is at risk for developing .
Correct Answer: A
Rationale: Tuberculosis is a bacterial infection that affects the lungs and can be transmitted through respiratory droplets. People with HIV are more susceptible to tuberculosis because their immune system is weakened by the virus. Tuberculosis can cause fever, cough, weight loss, and night sweats. The client's vital signs indicate that they have a fever and a high heart rate and respiratory rate, which could be signs of tuberculosis.
Extract:
Question 5 of 5
A nurse in an emergency department is caring for a client who has deep partial- and full thickness burns to his chest, abdomen, and upper arms. What is the nurse's priority intervention for this client during the resuscitation phase of injury?
Correct Answer: B
Rationale: This is because inhalation injury can cause airway edema, obstruction, and respiratory failure, which can be life-threatening. The nurse should monitor the client's respiratory status, administer oxygen, and prepare for intubation if needed.