ATI RN
ATI Advanced Med Surg Exam 4 Questions
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 1 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.
Extract:
Question 2 of 5
The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first?
Correct Answer: D
Rationale: Administering diphenhydramine first mitigates the risk of anaphylaxis from bee venom.
Extract:
Nurses Notes
1730: Report received from PACU:
Indwelling urinary catheter draining 850 mL dark red urine with clots, taped to left thigh, taut, no kinks. Continuous bladder irrigation with sterile water running.
22 g peripheral IV to left forearm: lactated Ringer's 125 mL/hr continuous infusion via pump.
Surgical incision to suprapubic area covered with gauze dressing with minimal amount of sanguineous drainage.
Post Op Day 1
0800:
Indwelling urinary catheter draining pink urine with small clots, attached to securement device on thigh, drainage bag attached to bed Catheter tube without kinks and patent, 150 mL in last 8hr.
Pain level 7 on 0 to 10 scale. Receiving morphine via PCA per pain management.
Scrotal and penile is edematous along with decreased urinary output Ecchymosis to skin surrounding surgical incision, moderate amount of serous drainage, cleansed with wound cleanser, patted dry, covered with 4X4 gauze dressing
Reports feeling bloated. Bowel sounds hypoactive. Last bowel movement day before surgery.
Vital Signs
Post Op Day 0
1730
Temperature: 37.3°C (99.2°F) oral
Heart rate: 72/min
Respiratory rate: 16/min.
Blood pressure: 116/68 mm Hg
Sa02: 98 % on room air
Post Op Day 1
0800
Temperature: 36.7°C (98.1°F) oral
Heart rate: 84/min
Respiratory rate: 20/min
Blood pressure: 148/76 mm Hg
Sa02-98% on room air
Question 3 of 5
A nurse is caring for a client who has had an open radical prostatectomy. For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.
| Options | Anticipated | Nonessential | Contraindicated |
|---|---|---|---|
| Administer a docusate sodium suppository. | |||
| Apply ice to the scrotum and penis. | |||
| Administer an antispasmodic medication. | |||
| Place the client in the sitting position while in bed. | |||
| Teach the client how to use a leg bag. |
Correct Answer: A,B,C,E
Rationale: A: Docusate sodium prevents constipation, common post-surgery. B: Ice reduces scrotal/penile edema. C: Antispasmodics manage catheter-related spasms. D: Sitting may not be necessary and could cause discomfort. E: Leg bag education is essential for catheter management.
Extract:
Question 4 of 5
Gastric lavage and administration of activated charcoal are prescribed for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action should the nurse plan to do first?
Correct Answer: B
Rationale: Intubation ensures airway protection before other interventions in an unconscious patient.
Question 5 of 5
During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next?
Correct Answer: C
Rationale: Further assessment for the cause of decreased circulation is critical to prevent limb loss.