ATI RN
ATI Advanced Med Surg Exam 4 Questions
Extract:
Nurses Notes
1730: Report received from PACU:
Indwelling urinary catheter draining 850 mL dark red urine with clots, taped to left thigh, taut, no kinks. Continuous bladder irrigation with sterile water running.
22 g peripheral IV to left forearm: lactated Ringer's 125 mL/hr continuous infusion via pump.
Surgical incision to suprapubic area covered with gauze dressing with minimal amount of sanguineous drainage.
Post Op Day 1
0800:
Indwelling urinary catheter draining pink urine with small clots, attached to securement device on thigh, drainage bag attached to bed Catheter tube without kinks and patent, 150 mL in last 8hr.
Pain level 7 on 0 to 10 scale. Receiving morphine via PCA per pain management.
Scrotal and penile is edematous along with decreased urinary output Ecchymosis to skin surrounding surgical incision, moderate amount of serous drainage, cleansed with wound cleanser, patted dry, covered with 4X4 gauze dressing
Reports feeling bloated. Bowel sounds hypoactive. Last bowel movement day before surgery.
Vital Signs
Post Op Day 0
1730
Temperature: 37.3°C (99.2°F) oral
Heart rate: 72/min
Respiratory rate: 16/min.
Blood pressure: 116/68 mm Hg
Sa02: 98 % on room air
Post Op Day 1
0800
Temperature: 36.7°C (98.1°F) oral
Heart rate: 84/min
Respiratory rate: 20/min
Blood pressure: 148/76 mm Hg
Sa02-98% on room air
Question 1 of 5
A nurse is caring for a client who has had an open radical prostatectomy. For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.
| Options | Anticipated | Nonessential | Contraindicated |
|---|---|---|---|
| Administer a docusate sodium suppository. | |||
| Apply ice to the scrotum and penis. | |||
| Administer an antispasmodic medication. | |||
| Place the client in the sitting position while in bed. | |||
| Teach the client how to use a leg bag. |
Correct Answer: A,B,C,E
Rationale: A: Docusate sodium prevents constipation, common post-surgery. B: Ice reduces scrotal/penile edema. C: Antispasmodics manage catheter-related spasms. D: Sitting may not be necessary and could cause discomfort. E: Leg bag education is essential for catheter management.
Extract:
Question 2 of 5
A nurse is teaching a client about the seven warning signs of cancer. Which of the following signs should the nurse include as manifestations of cancer? (Select all that apply.)
Correct Answer: B,C,E
Rationale: B: Bowel pattern changes can signal colorectal cancer. C: Nonhealing sores may indicate skin cancer. E: Persistent cough can suggest lung or throat cancer.
Extract:
Vital Signs
Blood pressure 180/90 mm Hg
Heart rate 105/min
Temperature 37.1° C (98.8 F)
Respirations 18min; labored
Pulse oximetry 94 on 2L nasal cannula
Medical History
History of coronary artery disease
Type 2 diabetes mellitus
Renal failure
Renal transplant 6 weeks ago
Nurses Notes
The client reports worsening fatigue over the last 3 days. The client also reports loss of appetite, denies nausea or vomiting.
On assessment, the client appears pale, lung and heart sounds within defined limits. Abdomen is tender in area of incision from transplant Bowel sounds are hypoactive in all 4 quadrants. Bilateral pedal pulses +2. +1 edema in bilateral lower extremities. Client reports that for the last 2 days they have only urinated twice per 24-hour period.
Diagnostic Results
BUN 25 mg/dL (10 to 20 mg/dL)
Creatine 2.0 mg/dL (0.5 to 1.3 mg/dL)
Hemoglobin 15 mmol/L (12 to 18 mmol/L)
Hematocrit 45% (37% to 52%)
Potassium 5.2 mEq/L (3.5 to 5.0 mEq/L)
Sodium 145 mEq/L (136 to 145 mEq/L)
Question 3 of 5
A nurse is caring for a client who is admitted to the emergency department for fatigue. Which of the following findings indicate that the client may be experiencing transplant rejection? (Select all that apply).
Correct Answer: A,B,E,F
Rationale: A: Incision tenderness indicates inflammation. B: Edema suggests kidney issues. E: High creatinine indicates rejection. F: Hypoactive bowels may indicate reduced perfusion.
Extract:
Question 4 of 5
The charge nurse is assigning semiprivate rooms for new admissions. Which patient could safely be assigned as a roommate for a patient who has acute rejection of an organ transplant?
Correct Answer: B
Rationale: Viral pneumonia is less likely to transmit infection to an immunocompromised transplant patient.
Question 5 of 5
A nurse is preparing to administer 0.45% sodium chloride (NaCl) 1000 mL IV to infuse over 8 hr. 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: 125
Rationale:
Total volume (1000 mL) divided by infusion time (8 hours) equals 125 mL/hr.