ATI RN
ATI SP 250 Exam 3 Med Surg Exam Questions
Extract:
Nurses' Notes
Vital Signs
Medication
Home health nurse admission note:
Client discharged from healthcare facility yesterday following a 4-day stay for exacerbation of COPD. Lives alone; alert and oriented to person, place, and time. Lung fields with scattered rhonchi throughout, cough productive for thick white sputum, dyspnea with minimal exertion.
Clubbing is noted on fingers, chest is barrel-shaped. Supplemental oxygen at 2L/min via nasal cannula.
Home Health Nurse Note 3 days following discharge from health care facility: Client sleeping in recliner with nasal canula on their lap; awakens easily and is oriented to person but disoriented to place and time.
Lung sounds with scattered rhonchi, cough productive for thick, yellow secretions. 2+pitting edema bilateral in ankles and feet.
Re-oriented client. Client states "I don't remember if I did that breathing machine thing you told me about."
Instructed client on oxygen use, safety, and nebulizer treatments. Elevated lower extremities.
Question 1 of 4
A nurse is caring for a client who has COPD. Select the 5 findings that require follow-up.
Correct Answer: A,C,D,E,F
Rationale: Disorientation may indicate hypoxia, infection, or medication side effects. Yellow sputum may indicate a bacterial infection that requires antibiotics. Nebulizer use may indicate that the client is not using it correctly or regularly as prescribed, which can affect their lung function and oxygenation. Ankle edema may indicate fluid overload or heart failure, which can worsen COPD symptoms and increase the risk of complications. Living alone may pose safety risks for the client, especially if they are disoriented or have difficulty managing their oxygen and nebulizer treatments.
Extract:
Question 2 of 4
A nurse is teaching a client who has tuberculosis and is to start combination drug therapy. Which of the following medications should the nurse plan to administer?
Correct Answer: A,D,E
Rationale: This is because these medications are antimycobacterial agents that inhibit the growth and replication of Mycobacterium tuberculosis, the bacterium that causes tuberculosis. Acyclovir is an antiviral medication, and montelukast is used for asthma.
Question 3 of 4
A nurse is admitting a client who has sustained severe burn injuries in a grease fire. The nurse shades in a diagram indicating the burned surface areas. Using the Rule of Nines, the nurse should estimate that the client has burned what percentage of body surface area? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 31.5
Rationale: The anterior chest wall and abdomen accounts for 18%, the left upper limb 9% (4.5% anteriorly and 4.5% posteriorly), and the right upper limb 4.5% (2.25% anteriorly and 2.25% posteriorly). (18+9+4.5) = 31.5%.
Extract:
Diagnostic Results
January:
• Laboratory: CD4 cell count 200 cells/mm³ (Normal range: 600-1500 cells/mm³)
June:
• Laboratory: CD4 cell count 90 cells/mm³ (Normal range: 600-1500 cells/mm³)
• Chest x-ray: Bilateral white infiltrates consistent with pneumonia
Question 4 of 4
A nurse in a community health clinic is caring for a client who has a history of HIV. For each of the following assessment findings for the client, identify if the finding is consistent with HIV stage I or HIV stage III (AIDS). Each finding may support more than one disease process.
| Options | HIV stage I | HIV stage III |
|---|---|---|
| CD4 cell count 200 cells/mm3 (600-1500 cells/mm3) | ||
| Weight changes | ||
| Chest x-ray showing bilateral white infiltrates consistent with pneumonia | ||
| Skin condition | ||
| Latest CD4 cell count |
Correct Answer: A,C,E
Rationale: CD4 cell count 200 cells/mm³ is consistent with HIV stage II or III, as it indicates significant immunosuppression. Chest x-ray showing bilateral white infiltrates consistent with pneumonia is indicative of HIV stage III (AIDS), as opportunistic infections like pneumonia are common. Latest CD4 cell count (90 cells/mm³) is consistent with HIV stage III (AIDS), as it is below 200 cells/mm³, a threshold for AIDS diagnosis.
Extract:
WBC
1,400/mm3
RBC
4.3 x 1012/L
Hgb
Hct
Platelets
Albumin
12.1 g/dL
36.5%
170,000/mm3
5 g/dL
Question 5 of 4
A nurse is caring for a client who is receiving cisplatin for treatment of ovarian cancer. The client's most recent complete blood count (CBC) is shown in the table below. It is important for the nurse to consider which of the following for the client?
Correct Answer: A,C
Rationale: The client has an increased risk of infection due to a low WBC count (1,400/mm³), indicating a compromised immune system. The client has an increased risk for bleeding due to a low platelet count (170,000/mm³), which impairs clotting ability.