ATI RN
ATI Medical Surgical 2 Final 2024 Assessment Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has lung cancer and is scheduled for a lobectomy. The nurse should prepare the client to expect which of the following after the procedure?
Correct Answer: D
Rationale: The placement of a chest tube is a standard part of care following a lobectomy. The chest tube allows for drainage of fluid and air from the pleural space, ensuring proper lung expansion and preventing complications such as pneumothorax. Patients should be educated about the chest tube's purpose, care, and the sensations they may experience while the tube is in place.
Question 2 of 5
A nurse is educating coworkers about how to minimize back strain and avoid repeated episodes of low back pain. Which of the following strategies should the nurse include? (Select all that apply.)
Correct Answer: A,D,E
Rationale: Avoiding prolonged sitting (
A) reduces pressure on the spine, promoting better posture and reducing strain. Sleeping in a side-lying position with flexed knees (
D) maintains spinal alignment, reducing back stress. Padded shoe insoles (E) improve foot support and body alignment, decreasing back strain. Sleeping on a soft mattress (
B) is incorrect as it may cause spinal misalignment. Applying heat for 10 minutes every hour (
C) is not a standard preventive measure and may not be practical.
Question 3 of 5
A nurse is caring for a group of critically ill clients. Which of the following clients are exhibiting potential manifestations of sepsis? (Select all that apply)
Correct Answer: B,C
Rationale:
Choice A: A temperature of 37.2°C (99°F) is slightly elevated but not necessarily indicative of sepsis. A heart rate of 88/min is within normal limits (60-100/min). This client's signs do not strongly suggest sepsis.
Choice B: A heart rate of 132/min and a respiratory rate of 30/min are both elevated, which can be signs of sepsis. Sepsis can cause an increase in heart rate (tachycardia) and respiratory rate (tachypnea) as the body attempts to maintain adequate blood flow and oxygenation during a systemic infection.
Choice C: A decrease in the level of consciousness combined with a heart rate greater than 130/min could indicate sepsis, as confusion or changes in mental status are common symptoms when the body is fighting a severe infection.
Choice D: Bradypnea, or abnormally slow breathing, is not typically associated with sepsis, which more commonly causes rapid breathing. A WBC count of 10,000/mm^3 is at the upper limit of the normal range and does not necessarily indicate sepsis without other symptoms.
Choice E: A temperature of 36°C (96.8°F) is on the lower end of the normal body temperature range and does not suggest fever, which is a common sign of sepsis. A respiratory rate of 16/min is within the normal range (12-20/min) and does not indicate sepsis.
Question 4 of 5
A nurse is caring for a 68-kg (150-lb) client who has dehydration. Which of the following manifestations is an indication of effective treatment?
Correct Answer: C
Rationale: Urine output of 75 mL in 1 hr is within the normal range for an adult (0.5 to 1 mL/kg/hr), indicating that the kidneys are functioning and the body is excreting waste, suggesting effective rehydration.
Question 5 of 5
The nurse is caring for a client who has prostate cancer. Which of the following manifestations does the nurse attribute to the advancing disease process?
Correct Answer: A
Rationale: Blood in the urine (hematuria) or semen (hematospermia) can be a sign of advanced prostate cancer. This symptom occurs when the cancer affects the urinary or reproductive tracts, causing bleeding. It is a direct result of the tumor invading nearby tissues or structures. While anemia can be associated with chronic diseases like cancer, it is not a direct manifestation of the advancing disease process of prostate cancer. Anemia in cancer patients is often multifactorial, including chronic inflammation, nutritional deficiencies, or treatment-related side effects. A dark-colored or elevated lesion is not typically associated with prostate cancer. Such lesions are more commonly related to skin cancers or other dermatological conditions. An enlarged liver or gallbladder can be a sign of metastasis in advanced cancer cases, including prostate cancer. However, it is less specific than blood in the urine or semen and can be caused by a variety of other conditions.