Questions 85

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ATI Nur258 Med Surg 2 Final Exam Questions

Extract:


Question 1 of 5

A nurse is caring for a client who has human immunodeficiency virus (HIV). Which of the following laboratory values would be most concerning to the nurse?

Correct Answer: D

Rationale: A WBC count of 800/mm³ is severely low and indicates a high risk for infection, which is particularly concerning in a client with HIV, as it suggests significant immunosuppression and vulnerability to opportunistic infections.

Question 2 of 5

A nurse witnesses a motor vehicle crash and finds a client who is not breathing. The nurse suspects the client has a cervical vertebrae fracture. Which of the following actions should the nurse take first?

Correct Answer: A

Rationale: The first priority in this situation is to open the client's airway using the jaw-thrust maneuver. This technique is preferred for clients with suspected spinal injuries to avoid further spinal cord damage. Ensuring the airway is open and providing oxygenation are immediate life-saving actions.

Extract:

Medical History
1600:
Client brought to facility by adult son who found the client on the floor of their living room "passed out from drinking." Client has 5.1-cm (2-in) laceration on forehead with dried blood present. The son states client "has been drinking my entire life. I don't know how they are still alive."
Plan:
Admit for alcohol use disorder, observe for alcohol withdrawal.

Vital Signs
1600
Admission:
Temperature 36.° C (97° F)
Blood pressure 98/66 mm Hg
Heart rate 76/min
Respiratory rate 16/min
Spo2 93% on room air

Diagnostic Results
1800:
Blood alcohol 360 mg/dL (nl. 0-50 mg/dL)
Complete blood count (CBC):
White blood cell (WBC) count 6,500/mm3 (nl. 5,000-10,000/mm3)
Red blood cell (RBC) count 4.0 million/mm3 (nl. 4.2 to 5.4 million/mm3)
Hemoglobin (Hgb) 11 g/dl (nl. 12-16 g/dL)
Hematocrit (Hct) 33% (nl. 36-48%)
Platelet count 350,000/mm3 (nl. 140,000-400,000/mm3)
Albumin 3.5 g/dL (nl. 3.5-5.2 g/dL)
Ammonia 79 mcg/dL (nl. 15-60 mcg/dL)


Question 3 of 5

Complete the following sentence by using the lists of options. The client is at highest risk for developing..... evidenced by the client's......

Correct Answer: A,B

Rationale: Encephalopathy is a complication of alcohol withdrawal, evidenced by elevated ammonia levels contributing to neurological symptoms.

Extract:


Question 4 of 5

A nurse is providing education about levothyroxine to a client diagnosed with primary hypothyroidism. Which of the following statements should the nurse use when teaching the client?

Correct Answer: A

Rationale: Levothyroxine is a thyroid hormone replacement used to treat hypothyroidism. Symptoms such as tremors, nervousness, and insomnia can indicate that the dose is too high, as these are signs of hyperthyroidism.

Question 5 of 5

The critical care nurse is preparing to initiate an infusion of a vasopressor medication to a client in septic shock. What goal of this treatment should the nurse identify?

Correct Answer: D

Rationale: The primary goal of vasopressor therapy in septic shock is to maintain an adequate mean arterial pressure (MAP) to ensure adequate organ perfusion and prevent organ failure.

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