ATI RN
ATI Medical Surgical 2 Final 2024 Assessment Questions
Extract:
Question 1 of 5
A nurse is caring for a 68-kg (150-lb) client who has dehydration. Which of the following manifestations is an indication of effective treatment?
Correct Answer: C
Rationale: Urine output of 75 mL in 1 hr is within the normal range for an adult (0.5 to 1 mL/kg/hr), indicating that the kidneys are functioning and the body is excreting waste, suggesting effective rehydration.
Question 2 of 5
A nurse is caring for a client whose throat culture is positive for group A streptococcus 24 hours after a rapid strep test (RST) was negative. Which of the following actions is the nurse's priority?
Correct Answer: D
Rationale: Notifying the client to return for antibiotic therapy is the priority, as group A streptococcus requires prompt treatment to prevent complications. Gargling, contact tracing, and fever management are secondary to initiating antibiotics.
Question 3 of 5
A nurse is planning to teach a client who is scheduled for an intravenous pyelogram (IVP). Which of the following statements should the nurse include in the teaching?
Correct Answer: B
Rationale: Encouraging fluid intake post-IVP helps flush out contrast dye, reducing kidney risks. Diet resumption depends on provider instructions, IVP uses X-rays not sound waves, and red blood cells in urinalysis do not typically cancel the procedure.
Question 4 of 5
A nurse is caring for a group of critically ill clients. Which of the following clients are exhibiting potential manifestations of sepsis? (Select all that apply)
Correct Answer: B,C
Rationale:
Choice A: A temperature of 37.2°C (99°F) is slightly elevated but not necessarily indicative of sepsis. A heart rate of 88/min is within normal limits (60-100/min). This client's signs do not strongly suggest sepsis.
Choice B: A heart rate of 132/min and a respiratory rate of 30/min are both elevated, which can be signs of sepsis. Sepsis can cause an increase in heart rate (tachycardia) and respiratory rate (tachypnea) as the body attempts to maintain adequate blood flow and oxygenation during a systemic infection.
Choice C: A decrease in the level of consciousness combined with a heart rate greater than 130/min could indicate sepsis, as confusion or changes in mental status are common symptoms when the body is fighting a severe infection.
Choice D: Bradypnea, or abnormally slow breathing, is not typically associated with sepsis, which more commonly causes rapid breathing. A WBC count of 10,000/mm^3 is at the upper limit of the normal range and does not necessarily indicate sepsis without other symptoms.
Choice E: A temperature of 36°C (96.8°F) is on the lower end of the normal body temperature range and does not suggest fever, which is a common sign of sepsis. A respiratory rate of 16/min is within the normal range (12-20/min) and does not indicate sepsis.
Question 5 of 5
A nurse is providing teaching to a client who has a prescription for heat therapy for the treatment of cellulitis of the right lower leg. Which of the following client statements indicates an understanding of the teaching?
Correct Answer: B
Rationale: Wrapping a warm, wet towel around the affected area (
B) is a safe and effective method for applying moist heat, which improves blood flow and reduces discomfort in cellulitis. Heat lamps (
A) risk burns and skin drying, heating pads (
C) may cause burns or exacerbate swelling, and soaking (
D) can introduce bacteria, worsening the infection.