ATI RN
ATI Advanced Med Surg Final Exam 0924 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has an epidural hematoma. Which of the following manifestations should the nurse expect?
Correct Answer: C
Rationale: An epidural hematoma often presents with a brief period of lucidity followed by a rapid decline in consciousness due to arterial bleeding.
Question 2 of 5
A nurse is caring for a client who has a T-4 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: D
Rationale: A distended bladder is a common trigger for autonomic dysreflexia in clients with a spinal cord injury at or above T-6, making it a key indicator for monitoring.
Extract:
Medical History
Day 1:
Patient came from ER complaining of chest pain. CPR initiated in ER and return to ROSC after 3 minutes. Intubated in ER (ACVC FIO2 100% Mode; RR13; PEEP 3: Tidal Volume 300ml and transferred to ICU for further care.
Nurses' Notes
Day 1:
S/p intubation, patient was given rocuronium, fentanyl and versed per radiology. Patient currently sedated. Lung crackles and bronchi. Heart regular and moderate. Pulses +1 on all extremities with +2 pitting edema. Hypoactive bowel sounds.
Diagnostic Results
Day 1:
Chest x-ray shows bilateral basilar infiltration
CBC
WBC 7.8
HGB13
K+3.9
Creatinine 2.0
BUN 60
GFR 38
BNP 1800
Troponin 1.7
ABG (Before intubation): pH7.2 CO2 76 HCO3 18
Vital Signs
Day 1
IN ER before cardiac arrest: Temperature 37.6° C (99.7° F)
Blood pressure 174/86 mm Hg
Heart rate 98/min
Respiratory rate 27/min
Pulse oximetry 93% on room air
After Intubation:
Temp 100.0F
Blood Pressure 87/40
HR 125/min. Sinus Tachycardia
RR: 13
Pulse Ox 100%
Question 3 of 5
For each potential nursing action, click to specify if the action is essential, nonessential, or contraindicated for the client.
| Options | Essential | Nonessential | Contraindicated |
|---|---|---|---|
| Administer furosemide | |||
| Administer ordered Epinephrine drip | |||
| Administer ordered low dose dopamine | |||
| Insert an indwelling urinary catheter | |||
| Administer ordered nitroglycerin | |||
| Administed 0.9% NS 500ML bolus |
Correct Answer: A,B,C,D,F
Rationale: Furosemide, epinephrine, dopamine, urinary catheter, and NS bolus are essential for managing pulmonary edema, hypotension, and monitoring fluid balance. Nitroglycerin is nonessential unless indicated for ongoing angina.
Extract:
Question 4 of 5
A nurse is preparing to administer ticarcillin/clavulanate 3.1 g by intermittent IV bolus over 30 min. Available is ticarcillin/clavulanate 3.1 g in 50 ml 0.9% sodium chloride (NSS). The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: B
Rationale: First, determine the total volume to be infused: 50 mL. Next, calculate the time in hours: 30 minutes is 0.5 hours. 50/0.5 = 100 mL/hr.
Question 5 of 5
A nurse is teaching a client who has a new diagnosis of acute bursitis in her right shoulder. Which of the following self-care strategies should the nurse recommend?
Correct Answer: B
Rationale: Intermittent ice and heat helps reduce inflammation and pain associated with acute bursitis.