ATI RN
ATI Med Surg Final Exam Nsg 232 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has burns on both arms, chest, abdomen and upper and lower back. Utilizing the Rule of Nines, the nurse estimates that the extent of the client's burns is which of the following percentages?
Correct Answer: D
Rationale: Using the Rule of Nines: each arm (9% x 2 = 18%), chest (9%), abdomen (9%), upper back (9%), lower back (9%) = 54% total body surface area burned.
Extract:
Nurses' Notes
1500:
Client presents to the ED and reports dyspnea, chest pain, and tachycardia. Client returned home from a vacation out of the country 24 hr ago.
1515:
The client has become diaphoretic, increasingly dyspneic, and states that their chest pain is sharp and increasing. The client states. "I feel like I'm going to die." Crackles auscultated in bilateral lower lobes, s3 and S4 heart sounds noted. Petechiae noted on the client's chest. Pulmonary embolism protocol initiated.
Vital signs
1500
T 38.1 (100.6 F),
HR 110/min, RR 24/min.
BP 138/52 (02)92% at 2L nasal canula 1515:
T 100.6 F,
HR 135/min, RR 32/min,
BP 120/50 mmHg,
02 90% at 4L nasal canula
Question 2 of 5
A nurse is caring for a client in the emergency department (ED). The nurse should first followed by
Correct Answer: A, E
Rationale: High Fowler's position improves breathing, and IV access prepares for medication administration in suspected pulmonary embolism.
Extract:
Client History
84-year-old client diagnosed with stage 4 lung cancer with metastasis to the brain and liver. Client lives with his daughter and her family, who are his main caregivers at home. Client's advance directives states that he does not want CPR, intravenous fluids, antibiotics, a feeding tube, or hospitalization at the end of life. Daughter is his health care power of attorney.
Nurse's Notes
Client sitting in recliner. Awake and confused, and insists he needs to go see his wife, who has been deceased for 15 years. Daughter states is very concerned because the client has become more agitated over the past two days and is not sleeping at night. Client's skin is hot and pale, oral mucosa dry. Breath sounds diminished throughout with coarse rhonchi on the right.
Productive cough with large amounts of thick, white sputum. Client reports "terrible" pain in his back that is not being relieved by his current pain medication. Taking sips of water but refuses food and reports having no appetite.
Vital Signs
B/P 108/60
HR 88 irregular
Temp 100.8 F (38.22 C)
RR 18
Sp 02 92% on 2L 02
Question 3 of 5
A nurse caring for a client who is at home on hospice care. At the end of the visit, the nurse reevaluates the client. Indicate if the assessment findings are improved, show no change, or show that the client has declined.
| Options | Improved | No change Declined |
|---|---|---|
| Client calm not agitated. Grimaces with movement. | ||
| Oral mucous membranes dry. | ||
| Axillary temp 102 F (38.9 C), client shivering. | ||
| Productive cough. | ||
| Coarse rhonchi bilaterally. Crackles in bases. | ||
| Respirations irregular with periods of apnea | ||
| Client resting in recliner. RR 12, regular |
Correct Answer: No change, No change, Declined, No change, Declined, Improved, Improved
Rationale: Calmness with grimacing indicates no change in pain; dry mucosa and productive cough persist; increased temperature and worsening lung sounds indicate decline; regular respirations and lower RR show improvement.
Extract:
Question 4 of 5
A nurse is caring for a client who experienced sudden onset of dyspnea, tachycardia, oxygen saturation of 82%, and has been intubated with an endotracheal tube. The nurse should perform which priority action immediately after the tube is placed in the trachea?
Correct Answer: B
Rationale: Auscultating both lungs confirms correct tube placement and adequate ventilation, critical immediately post-intubation.
Question 5 of 5
A nurse is caring for a client diagnosed with a pulmonary embolism that is placed on a continuous heparin infusion. The nurse should notify the health care provider for which of the following findings?
Correct Answer: D
Rationale: An elevated PTT (70 seconds) indicates a potential heparin overdose, increasing bleeding risk, requiring immediate provider notification.