ATI RN
ATI Advanced Med Surg Exam 4 Questions
Extract:
Physical Examination
January:
Weight 70.5 kg (155 lb)
BMI 24
February:
Weight 69 kg (152 lb)
BMI 23
Diagnostic Results
January:
Complete Blood Count:
RBC count 4.2 (4.2 to 5.4)
WBC count 5,500/mm3 (5,000 to 10,000/mm3)
Hgb 12 g/dl (12 g/dL to 16 g/dL)
Het 37% (37% to 47%)
Platelet count: 150,000/mm2 (150,000 to 400,000/mm
February:
Complete Blood Count
WBC count: 4,500/mm2 (5,000 to 10.000/mm3)
RBC count 4 (4.2 to 5.4)
Hgb: 14 g/dL (15 g/dl to 16 g/dl
Het 36 (376 to 4796)
Platelet count: 140,000/mm(150.000 to 400,000/mm3)
Nurses' Notes
January:
Client reports fatigue and nausea following chemotherapy treatments. States, "It just makes me not want to eat. When I do eat, the food taste funny."
Client teaching: Instructed client to attempt to eat small meals several times daily, to eat food cold or at room temperature, to avoid fried foods. Encourage client to rest before eating meals.
Oral mucosa is inflamed.
Client teaching: Instructed client to avoid mouthwashes that contain alcohol, to increase water intake to 2 or more liters daily, and to avoid hot foods.
Reviewed laboratory findings and stressed the need to protect self from illness due to immunosuppression.
Client teaching: Instructed client to not eat raw or undercooked meat, to drink only pasteurized milk, and to boil water before drinking it take temperature daily and report fever, avoid crowds, wash hands frequently with antimicrobial soap.
Reviewed laboratory findings and stressed need for bleeding precautions. Client states, "I’ve had bleeding from these ulcers in my mouth.”
Client teaching Use an electric razor take a stool softener if constipation occurs, avoid coarse-textured foods.
February
Client has experienced weight loss of 1.5 kg (3 B), has experienced decrease in hct and high, WBC and platelet count.
Client reports still not able to consume much food has increased intake
of water. Oral mucosa with less inflammation.
Client reports no bleeding episodes.
Question 1 of 5
A nurse is caring for a client who has cancer and is undergoing chemotherapy. Which of the following assessments indicates an improvement in the client's condition? (Select all that apply.)
Correct Answer: A,C,D
Rationale: A: A decrease in WBC count may indicate reduced chemotherapy-induced immunosuppression. C: Absence of bleeding episodes suggests improved mucosal integrity. D: Reduced oral inflammation indicates effective interventions. E: Weight loss does not indicate improvement.
Extract:
Question 2 of 5
A nurse is assisting with triaging clients following an explosion. Which of the following clients should the nurse identify as the highest priority?
Correct Answer: C
Rationale: Unconscious client with severe head injury and no respirations requires immediate intervention.
Question 3 of 5
A nurse is preparing to administer 0.9% sodium chloride IV infusion 1-L bag at a rate of 200 mL/hr for a client who has rhabdomyolysis. The nurse should expect the IV pump to infuse over how many hours? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 5
Rationale:
Total volume (1000 mL) divided by infusion rate (200 mL/hr) equals 5 hours.
Question 4 of 5
A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse expect for this patient?
Correct Answer: D
Rationale: Mycophenolate is an immunosuppressant used to manage acute rejection.
Question 5 of 5
A home health nurse is interviewing a client and asks the client, "Have you or your family been exposed to any chemical liquids, fumes, lead, or unusual smells?" Which type of assessment is the nurse conducting?
Correct Answer: C
Rationale: Asking about chemical exposure assesses environmental health risks.