ATI RN
ATI Med Surg 2 Respiratory exam Questions
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 1 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 2 of 5
A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?
Correct Answer: C
Rationale: Movement of the trachea towards the unaffected side is a sign of tension pneumothorax, which requires immediate intervention as it can compromise respiratory function.
Question 3 of 5
A nurse admits a client to the emergency department who reports nausea and vomiting that worsens when he lies down. Antacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see?
Correct Answer: D
Rationale: Increased serum amylase is a hallmark of acute pancreatitis as the damaged pancreas releases more amylase into the blood.
Question 4 of 5
A nurse is assessing a client who is 2 weeks postoperative following a kidney transplant. Which of the following manifestations should the nurse identify as possible organ rejection?
Correct Answer: C
Rationale: Oliguria (reduced urine output) is a primary sign of kidney transplant rejection. It indicates that the transplanted kidney is not functioning properly, which is a critical indicator of rejection.
Question 5 of 5
A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD) and is short of breath. When reviewing the client's arterial blood gases (ABGs) which of the following conditions should the nurse anticipate the client to be experiencing?
Correct Answer: B
Rationale: Respiratory acidosis occurs due to impaired gas exchange and carbon dioxide retention in COPD.