ATI RN
ATI Med Surg 2 Respiratory exam Questions
Extract:
Question 1 of 5
A nurse is assessing a client who has suspected acute respiratory distress syndrome (ARDS). The nurse should identify which of the following is the most common presenting manifestation of ARDS?
Correct Answer: D
Rationale: Dyspnea, or difficulty breathing, is the hallmark of ARDS and the most common presenting symptom due to acute hypoxemia.
Question 2 of 5
A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following should the nurse include in the teaching?
Correct Answer: A
Rationale: Obtaining an influenza vaccine annually is crucial for individuals with type 1 diabetes to reduce the risk of infections that can exacerbate their condition.
Extract:
History and Physical
The client has a history of coronary artery disease, type 2 diabetes mellitus, renal failure, and had a renal transplant 6 weeks ago. The client reports worsening fatigue over the last 3 days and loss of appetite but denies nausea or vomiting.
Vital Signs
• Blood pressure: 180/90 mm Hg
• Heart rate: 105/min
• Temperature: 37.1° C (98.8° F)
• Respirations: 18/min, labored
• Pulse oximetry: 94% on 2L nasal cannula
Nurses Notes
The client appears pale on assessment. Lung and heart sounds are within defined limits. The abdomen is tender in the area of the incision from the transplant. Bowel sounds are hypoactive in all four quadrants. Bilateral pedal pulses are +2. The client has +1 edema in bilateral lower extremities. The client reports urinating only twice per 24-hour period for the last 2 days
Diagnostic Results
• BUN: 25 mg/dL (10 to 20 mg/dL)
• Creatinine: 2.0 mg/dL (0.5 to 1.3 mg/dL)
• Hemoglobin: 15 mmol/L (12 to 18 mmol/L)
• Hematocrit: 45% (37% to 52%)
• Potassium: 5.2 mEq/L (3.5 to 5.0 mEq/L)
• Sodium: 145 mEq/L (136 to 145 mEq/L)
Physical Examination Results
The incision site on the abdomen is tender to touch, with mild redness and swelling. The client has bilateral pedal pulses that are +2 and exhibits +1 edema in both lower extremities. The client’s bowel sounds are hypoactive in all four quadrants. The client appears pale, and reports urinating only twice per day for the last 2 days
Question 3 of 5
A nurse is caring for a 65-year-old male client who is admitted to the emergency department for fatigue. Which of the following findings indicate that the client may be experiencing transplant rejection? (Select all that apply)
Correct Answer: A,B,C
Rationale: Tenderness, redness, and swelling at the incision site, edema in the lower extremities, and elevated blood pressure can indicate transplant rejection.
Extract:
Question 4 of 5
A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan?
Correct Answer: D
Rationale: Placing the client in a prone position has been shown to improve oxygenation in ARDS by enhancing lung expansion and ventilation-perfusion matching.
Extract:
History and Physical
The client has a history of type 1 diabetes mellitus for 16 years, which is managed with insulin at bedtime and before each meal. The client measures capillary blood glucose twice daily. He had a motor-vehicle crash 3 years prior.
Nurses Notes
The client is lethargic and rouses with physical stimulation. His Glasgow Coma Scale score has decreased from 14 to 12. Auscultation of the lungs reveals rales in the right lower lobe. The right upper lobe is diminished but clear. Kussmaul respirations are noted. An 18-gauge IV in the right forearm is edematous and cool to touch. Capillary refill is 3 seconds. He has dry mucous membranes and decreased skin turgor.
Vital Signs
• Supine blood pressure: 100/70 mm Hg
• Sitting blood pressure: 85/50 mm Hg
• Heart rate: 120/min
• Respiratory rate: 24/min
• Temperature: 37.9°C (100.2°F)
• Oxygen saturation: 95% on room air
Medical History
The client was admitted to the unit from the emergency department. The client's partner reports lethargy, vomiting, diarrhea, and fever lasting for 2 days.
Diagnostic Results
• Casual blood glucose: 580 mg/dL (normal: <200 mg/dL)
• Sodium: 152 mEq/L (normal: 136-145 mEq/L)
• Potassium: 5.3 mEq/L (normal: 3.5-5.0 mEq/L)
• BUN: 32 mg/dL (normal: 10-20 mEq/L)
• Creatinine: 1.8 mg/dL (normal: 0.5-1.3 mg/dL)
• Serum pH: 7.2 (normal: 7.35-7.45)
• HCO3-: 13 mEq/L (normal: 21-28 mEq/L)
• Urine reagent strip testing: pH 4.4 (normal: 4.6-8.0), Specific gravity: 1.036 (normal: 1.005-1.030), Ketones: positive (negative), Glucose: present (none)
• Glycosylated hemoglobin: 9.69% (normal: <7.9% indicates good diabetic control)
ECG Findings
ECG indicates tachycardia with a prolonged PR interval, widened QRS, and peaked T waves.
Question 5 of 5
A nurse is admitting a 45-year-old male client who has type 1 diabetes mellitus in the emergency department. Select the findings that require immediate attention.
Correct Answer: A,C,F,G,H
Rationale: The Glasgow Coma Scale score decrease indicates worsening neurological status. Low bicarbonate suggests metabolic acidosis. Hypotension indicates hemodynamic instability. ECG findings suggest hyperkalemia. Hypernatremia requires prompt correction.