ATI RN
ATI SP 250 Exam 3 Med Surg Exam Questions
Extract:
Vital Signs
• Temperature 38.1° C (100.6° F)
• Heart rate 122/min
• Respiratory rate 26/min
• BP 136/85 mm Hg
• Oxygen saturation 93% on room air
Question 1 of 5
A nurse is caring for a client who has HIV. The client is at risk for developing .
Correct Answer: A
Rationale: Tuberculosis is a bacterial infection that affects the lungs and can be transmitted through respiratory droplets. People with HIV are more susceptible to tuberculosis because their immune system is weakened by the virus. Tuberculosis can cause fever, cough, weight loss, and night sweats. The client's vital signs indicate that they have a fever and a high heart rate and respiratory rate, which could be signs of tuberculosis.
Extract:
Question 2 of 5
A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?
Correct Answer: C
Rationale: This is because central cyanosis reflects a decrease in arterial oxygen saturation and is best seen in areas where blood vessels are close to the surface, such as the oral mucosa, tongue, and lips. Peripheral cyanosis, which may be caused by vasoconstriction or poor circulation, can be seen in the soles of the feet, ear lobes, and nail beds, but it does not necessarily indicate hypoxemia.
Question 3 of 5
A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?
Correct Answer: D
Rationale: This is because burns to the face, neck, and upper extremities can compromise the airway, circulation, and mobility of the client. The nurse should monitor for signs of respiratory distress, infection, and contractures in these areas.
Question 4 of 5
A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client?
Correct Answer: D
Rationale: This is because emphysema causes destruction of alveolar walls and loss of elastic recoil, which leads to air trapping and hyperinflation of the lungs. This results in a barrel-shaped chest and increased chest circumference.
Question 5 of 5
A nurse is caring for a client who is taking aspirin for arthritis. The nurse should identify which of the following findings as an adverse effect of this medication?
Correct Answer: A
Rationale: This is because aspirin can cause salicylate toxicity, which can manifest as tinnitus, hearing loss, vertigo, headache, confusion, and hyperventilation. The nurse should monitor the client's serum salicylate level and advise the client to report any signs of toxicity to the provider.