ATI RN
ATI RN Adult Medical Surgical 2023 V Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has a peripherally inserted central catheter (PICC) line in her left forearm. The client is receiving an antibiotic via intermittent IV bolus every 12 hr. Which of the following actions should the nurse take in managing the client's PICC line?
Correct Answer: A
Rationale: Flushing with saline after use maintains PICC patency and prevents occlusion.
Question 2 of 5
A nurse is teaching a client who has AIDS and wishes to continue self-care at home despite living alone. Which of the following actions by the nurse demonstrates client advocacy?
Correct Answer: A
Rationale: A home health referral supports the client's desire for independence while ensuring safe care.
Extract:
Nurses' Notes
0900:
Client came to the emergency department this morning and reports not feeling well for the last 12 hr and increasing blood glucose. Client has a history of type 1 diabetes mellitus and hypertension. Client weight is 88 kg (194 lb). The client was recently treated for bronchitis and pneumonia. Client reports nausea and decreased appetite.
Client is alert and orientated x 4, heart and lung sounds are clear. Client states that they have been frequently urinating and are extremely thirsty. Bowel sounds are hyperactive in all 4 quadrants. Bilateral pedal pulses 1+. Slight tenting of skin. Peripheral IV established and labs drawn.
Vital Signs
0900:
• Temperature 36.8° C (98.2° F)
• Pulse rate 110/min
• Respiratory rate 18/min
• Blood pressure 96/65 mm Hg
• Oxygen saturation 96% on room air
Laboratory Results
0915:
• Blood glucose 468 mg/dL (74 to 106 mg/dL)
• pH 7.30 (7.35 to 7.45)
• Potassium 5.5 mEq/L (3.5 to 5 mEq/L)
• Sodium 138 mEq/L (136 to 145 mEq/L)
• Chloride 101 mEq/L (98 to 106 mEq/L) BUN 21 mg/dL (10 to 20 mg/dL)
• Creatinine 1.7 mg/dL (0.5 to 1.1 mg/dL)
• Urine dipstick positive for ketones (negative)
Question 3 of 5
A nurse is caring for a client in the emergency department. For each assessment finding, click to specify if the assessment finding is consistent with diabetic ketoacidosis (DKA) or hyperglycemic-hyperosmolar state (HHS). Each finding may support more than 1 disease process.
Correct Answer: A,B,C,D
Rationale: Poor skin turgor, high glucose, and elevated creatinine are common in both DKA and HHS; ketones are specific to DKA.
Question 4 of 5
A nurse is caring for a client in the emergency department. The nurse understands that the client is at risk of developing which of the following complications? Select all that apply.
| Options | DKA | HHS |
|---|---|---|
| Hypotension | ||
| Respiratory alkalosis | ||
| Septic shock | ||
| Cardiac arrhythmias | ||
| Renal failure | ||
| Cerebral edema |
Correct Answer: A,D,E,F
Rationale: Hypotension, arrhythmias (from hyperkalemia), renal failure (from dehydration), and cerebral edema are DKA risks.
Question 5 of 5
A nurse is caring for a client in the emergency department. Which of the following 3 provider prescriptions does the nurse anticipate?
Correct Answer: B,D,E
Rationale: Cardiac monitoring, IV insulin infusion, and saline rehydration are standard DKA treatments.