ATI RN
ATI Nur258 Med Surg 2 Final Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has a T4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?
Correct Answer: B
Rationale: Bladder distension is a common trigger for autonomic dysreflexia, a condition that occurs in individuals with spinal cord injuries at or above the T6 level, due to the excessive autonomic response to noxious stimuli such as a full bladder.
Extract:
Nurses notes
Day 1:
Place the client on
Client reports fatigue, weight loss, and anorexia. Chemotherapy started as prescribed.
droplet precautions.
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:
Hematocrit (Hct) 38% (nl. 36-48%)
Hemoglobin (Hgb) 13 g/dL (nl. 12-16 g/dL)
Platelet 180,000/mm3 (nl. 150,000-400,000/mm3)
Total white blood cell (WBC) count 7000/mm3 (nl. 5,000-10,000/mm3)
4 weeks later:
Hct 35% (nl. 36-48%)
Hgb 11 g/dL (nl. 12-16 g/dL)
Platelet 100,000/mm3 (nl. 150,000-400,000/mm3)
Total WBC count 3000/mm3 (nl. 5,000-10,000/mm3)
with 0.9% sodium chloride every 4 hrs.
Question 2 of 5
For each potential healthcare provider's prescription at 4 weeks, click to specify if the prescription is anticipated, nonessential, or contraindicated for the client.
Correct Answer: A,C,E
Rationale: Placing the client on droplet precautions is anticipated to prevent infection in immunocompromised patients. A private room is anticipated to reduce infection risk. Rinsing the client's mouth with 0.9% sodium chloride is anticipated to manage sore mouth and maintain oral hygiene.
Extract:
Question 3 of 5
An immunocompromised older adult has developed a urinary tract infection, and the healthcare team recognizes the need to prevent an exacerbation of the client's infection that could result in sepsis and septic shock. What action should the nurse perform to reduce the client's risk of septic shock?
Correct Answer: C
Rationale: Initiating intravenous (IV) antibiotics is the most critical intervention to reduce the risk of septic shock. Prompt administration of antibiotics can help control the infection before it progresses to sepsis, making this the priority action.
Question 4 of 5
A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the healthcare provider?
Correct Answer: A
Rationale: Difficulty swallowing in a client with facial burns can indicate airway compromise due to edema and should be reported immediately as it may require urgent intervention to secure the airway.
Question 5 of 5
A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations is the priority for the nurse to report to the healthcare provider?
Correct Answer: A
Rationale: A decrease in the Glasgow Coma Scale score from 13 to 10 indicates a significant change in consciousness and may suggest worsening of the brain injury. This is a critical sign that requires immediate reporting and evaluation.