ATI RN
ATI Advanced Med Surg Exam 4 Questions
Extract:
Nurses' Notes
40-year-old client is 2 days post-op following a renal transplant. Client alert and oriented x3. Sitting in high Fowler's. Skin warm and dry. Client reports pain at incision site as 5 on a scale of 0 to 10. Incision approximated, sutures intact. No drainage noted. Heart sounds regular. Lung sounds diminished throughout. Instructed to use incentive spirometer. Abdomen soft and non-distended. Bowel sounds hypoactive x4. 1+ peripheral edema noted bilaterally. Foley catheter patent, urine pink tinged. Urine output in last hour 1500mL
Vital Signs
Temperature 37.7° C (99.8° F)
Heart rate 110/min
Respiration rate 24/min
BP 94/56 mm Hg
Oxygen saturation 96% on room air
Question 1 of 5
A nurse is caring for a 40-year-old client in a transplant unit. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Correct Answer: A, A, C, A, B
Rationale: Hypovolemia indicated by high urine output and low BP. Lower bed and IV bolus address hypovolemia; monitor urine output and BP.
Extract:
Question 2 of 5
A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse expect for this patient?
Correct Answer: D
Rationale: Mycophenolate is an immunosuppressant used to manage acute rejection.
Question 3 of 5
During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient has an unobstructed airway. Which action should the nurse take next?
Correct Answer: D
Rationale: Observing respiratory effort ensures adequate breathing in the primary survey.
Question 4 of 5
An occupational health nurse at a factory has been asked to investigate an employee injury claim. Which of the following information should the nurse review?
Correct Answer: B
Rationale: Workplace procedures and protocols are directly relevant to investigating injury circumstances.
Extract:
Nurses' Notes
Day 1
Client reports fatigue, weight loss, and anorexia, Chemotherapy started as prescribed.
4 weeks later
Client reports sore mouth and increased fatigue. Multiple bruises noted on elbows and legs.
Voided 350 mL of clear yellow urine.
Diagnostic Results
Day 1
Hct 38% (37% to 4796)
Hgb 13 g/dL (12 g/dL to 16 g/dL)
Platelet 180,000/mm3 (150,000 to 400,000/mm3)
Total WBC count 7000/mm? (5,000 to 10,000/mm3)
4 weeks later
Hct 35% (37% to 4796)
Hgb 11 g/dl. (12 g/dl to 16 g/dL)
Platelet 100,000/mm2 (150,000 to 400,000/mm)
Total WBC count 3000mm (5000 to 10,000/mm3).
Question 5 of 5
A nurse is caring for a client who has a new diagnosis of lung cancer. For each potential provider's prescription at 4 weeks, click to specify if the prescription is anticipated, nonessential, or contraindicated for the client.
| Options | Anticipated | Nonessential | Contraindicated |
|---|---|---|---|
| Rinse the client's mouth with 0.9% sodium chloride every 4 hr. | |||
| Check the client's rectal temperature once daily. | |||
| Place the client in a private room. | |||
| Insert an indwelling urinary catheter. | |||
| Place the client on droplet precautions |
Correct Answer: A,C
Rationale: A: Mouth rinses prevent mucositis. C: Private rooms reduce infection risk in immunocompromised clients. B, D, E are not indicated.