ATI RN
ATI Advanced Med Surg Final Exam 0924 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Using log rolling to reposition the client helps to maintain spinal alignment and prevent increases in ICP.
Extract:
Nurses' Notes
Day 1:
0900:
Client admitted from emergency department with hemoptysis, dull chest pain, increasing fatigue, anorexia, nausea, chest tightness, and 3.2 kg (7 lb) weight loss in 2 weeks. Heart rate regular, lung sounds with crackles in bilateral upper lobes. No edema. Airborne precautions initiated upon admission.
Day 2:
1100:
Client reports shortness of breath, nausea, and fatigue. Crackles auscultated bilaterally throughout lung fields. Productive cough, with thick, blood-streaked sputum. Bowel sounds active, no edema.
Day 3:
0900:
Client reports some improvement in dyspnea. Client coughing up thick, yellow, blood-streaked sputum. Crackles auscultated in bilateral upper lobes of lungs. Sclera noted to be yellow. Client’s weight is 0.7 kg (1.6 lb) less than at admission. Encouraged to increase intake of oral fluids. Client reports urine appears reddish orange in color.
Medical history
Client has no chronic illnesses. Traveled out of the country 2 months ago.
Vital Signs
Day 1:
Temperature 38.6°C (101.4°F)
Heart rate 96/min
Respiratory rate 26/min
Blood pressure 158/88 mm Hg
Oxygen saturation 91% on room air
Day 2:
Temperature 38.4°C (101.2°F)
Heart rate 88/min
Respiratory rate 24/min
Blood pressure 152/82 mm Hg
Oxygen saturation 92% on 02 at 4L/min via nasal cannula
Day 3:
Temperature 37.8°C (100.1°F)
Heart rate 82/min
Respiratory rate 22/min
Blood pressure 130/78 mm Hg
Oxygen saturation 96% on 02 at 4L/min via nasal cannula
Provider prescriptions
Day 1:
Purified protein derivative 0.1 mL intradermal to right forearm
Isoniazid 300 mg PO daily
Rifampin 600 mg PO daily
Acetaminophen 500 mg 1-2 tablets PO every 4 to 6 hr PRN fever, pain
Diagnostic Results
Day 1
ALT 36 SI/L (4-36 SI/L)
AST 35 units/L (0-35 units/L)
Alkaline phosphatase 118 units/L (30-120 units/L)
Chest x-ray caseation with inflammation throughout upper lobes
Day 3:
Mantoux Test: 12 mm induration (negative, reaction less than 5 mm) ALT 38 SI-36 SI/L)
AST 36 units/L (0-35 units/L)
Alkaline phosphatase 129 units/L (30-120 units/L)
Question 2 of 5
A nurse on a medical-surgical unit is caring for a newly admitted client with a diagnosis of R/O tuberculosis. Which of the following findings should the nurse report to the provider?
Correct Answer: A
Rationale: Yellow sclera indicates jaundice, which could be a sign of liver dysfunction, especially concerning given the client is on isoniazid and rifampin, which can cause hepatotoxicity.
Extract:
Question 3 of 5
A nurse is assessing a client who has right ventricular failure. Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: Hepatomegaly is a common finding in right ventricular failure due to increased pressure in the venous system.
Question 4 of 5
A nurse is teaching an assistive personnel (AP) about the purpose of a footplate on the bed of a client whose leg is in Buck's traction. Which of the following statements indicates the AP understands the teaching?
Correct Answer: B
Rationale: The footplate helps to prevent foot drop by maintaining proper alignment of the foot and leg in Buck's traction.
Question 5 of 5
A nurse is teaching a client who is postoperative following the insertion of a permanent pacemaker. Which of the following instructions should the nurse include? (Select all that apply)
Correct Answer: B,C,D
Rationale: Handheld metal detectors can interfere with pacemaker function, so requesting a manual search is appropriate. Monitoring the pulse daily ensures pacemaker functionality. Avoiding tight clothing prevents discomfort and interference with the pacemaker.