ATI RN
ATI Med Surg Pharm Comprehensive Exam 1 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take? (Select all that apply.)
Correct Answer: B,C,D
Rationale: Monitoring peripheral pulses helps assess circulation and neurovascular status in the affected extremity. Examining the skin under the traction splint is essential to assess for skin integrity and prevent complications like pressure ulcers. Assessing the temperature of the affected extremity helps detect signs of circulatory impairment or infection.
Question 2 of 5
A nurse is preparing to administer 10 units of regular insulin and 20 units of NPH insulin to a client who has diabetes mellitus. When mixing the two types of insulin, which of the following actions should the nurse take first?
Correct Answer: B
Rationale: Injecting air into the NPH insulin vial ensures that the proper amount of insulin can be withdrawn without creating a vacuum.
Extract:
Vital Signs
1200:
Temperature 38.6° C (10.5° F)
Heart rate 109/min
Respiratory rate 28/min
Blood pressure 106/54 mm Hg
Oxygen saturation 94% on room air
Nurses' Notes
Client presents to ED with report of shortness of breath for 2 days, with headache, chills, fever, sore throat, and cough. States they went to a music concert recently "and probably picked up some kind of virus." Oriented to person, place, and time. Appears lethargic, difficulty answering questioning due to shortness of breath. Follows simple commands, moves all extremities with weakness.
Client's face is flushed, sinus tachycardia, rate of 109/min, S152 heart sounds heard on auscultation. Pulses palpable.
Breath sounds with crackles to right lower lobe, tachypnea, rate of 28/min. Frequent productive cough with thick yellow sputum. Client denies hemoptysis. Unable to lie down, states they are "more comfortable sitting up."
Bowel sounds active x 4 quadrants. Denies diarrhea, last bowel movement yesterday. States "no appetite since I've been sick."
Reports decreased urination over past 24 hr. "Haven't been drinking as much water as I should because my throat hurts."
Client reports they have not had a pneumococcal vaccine and does not get annual influenza vaccinations. States, "I just hate needles."
Diagnostic Results
1230:
Chest x-ray:
Areas of increased density and white infiltrates to lower right lobe indicative of pneumonia
Medical History
1215:
70 years of age
No significant medical history other than primary concern
Well nourished
Home Medications:
Daily multi-vitamin
Vitamin D
Social History.
Lives alone, partner died 5 years ago
Drinks 1 to 2 glasses of red wine daily
Has never smoked
Walks 2 to 3 miles 6 days/week
Question 3 of 5
Select 4 findings in the client's medical record that place them at risk for pneumonia.
Correct Answer: A,C,E,F
Rationale: The client has not received pneumococcal vaccine, which increases susceptibility to pneumococcal pneumonia. The client has not received influenza vaccine, which increases susceptibility to influenza-related pneumonia. The client's fluid intake seems to be reduced, as indicated by their decreased urination and reports of not drinking much water due to a sore throat, which can contribute to the risk of infection. Being 70 years old increases susceptibility to respiratory infections like pneumonia.
Extract:
Question 4 of 5
The nurse collects blood from the client during peripheral IV line placement. What laboratory specimens would the nurse expect for the provider to order? Select all that apply.
Correct Answer: A,B,C,D,E,F,G
Rationale: A complete blood count is commonly ordered to assess overall health and detect conditions like anemia or infection. Electrolytes are checked to evaluate fluid and electrolyte balance. BUN and creatinine are used to assess kidney function. Coagulation studies are important to evaluate bleeding risk. Blood cultures may be ordered if infection is suspected. Blood glucose is relevant for metabolic assessment.
Extract:
Nurses' Notes
0800: Client reports abdominal pain that began the previous evening. Client is two weeks postoperative from a right knee replacement. Reports taking 3 to 4 hydrocodone tablets daily for postoperative pain. Has not had bowel movement in 4 days. Reports not drinking many fluids to avoid having "to get up and go to the bathroom so often because it hurts to walk."
0830: Client taken for abdominal x-ray. Partner reports that client has not been following physical therapist's exercise regimen of walking several times daily.
0915: Fecal mass of hard, dry stool removed digitally from client per provider's order.
1015: Provided teaching to client and partner about constipation and methods to avoid further impaction.
Diagnostic Results
0900:
Abdominal x-ray: Large amount of fecal material throughout the colon with rectal impaction. No evidence of small bowel obstruction.
Question 5 of 5
A nurse is providing teaching to a client who has constipation. Which of the following information should the nurse include?(Select all that apply.)
Correct Answer: C,D,E
Rationale: Including probiotic foods in the diet can help maintain a healthy gut flora, which is beneficial for digestion and preventing constipation. It is crucial to increase fluid intake, aiming for at least 1500 mL daily, to help soften the stool and support regular bowel movements. Increasing daily exercise, especially walking, can stimulate the muscles involved in the digestive process and help prevent constipation.