ATI RN
ATI Advanced Med Surg Final Exam 0924 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the postoperative period?
Correct Answer: B
Rationale: Performing neurovascular checks of the extremities is the most important action to identify complications such as compartment syndrome or impaired circulation.
Question 2 of 5
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)
Correct Answer: B,C,E
Rationale: Increased respiratory rate can occur as the body tries to compensate for fluid overload, which may affect lung function and cause respiratory distress. Increased blood pressure is a common finding in fluid overload due to increased blood volume in the circulatory system. Increased heart rate can occur as the body compensates for increased blood volume and higher blood pressure.
Question 3 of 5
A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the postoperative period?
Correct Answer: B
Rationale: Performing neurovascular checks of the extremities is the most important action to detect complications such as compartment syndrome or impaired circulation.
Extract:
Vital Signs:
1500:
Temperature 37.3° C (99.1° F)
BP 154/64 mm Hg
Heart rate 105/min
Respiratory rate 26/min
Oxygen saturation 93% on room air
Medical History
Cirrhosis
Hypertension, controlled with metoprolol therapy
Type 2 diabetes mellitus, controlled with glipizide therapy
Physical Examination
1500:
Client presents with decreased level of consciousness, slurred speech, and impaired concentration. Client is lethargic, does not respond to questions or simple commands. Pupils round, reactive to light and accommodation. Partner states client has been sleeping during the day and remains awake at night.
Skin is dry and jaundiced with petechiae present to arms and legs.
S1 S2 heard on auscultation. +1 pulses on bilateral radial and pedal pulses. Peripheral edema +3 present in bilateral lower extremities.
Crackles auscultated in bilateral lower lobes.
Abdomen distended with ascites. Hypoactive bowel sounds present in all four quadrants. Partner reports no knowledge of rectal bleeding, states client has been tolerating diet with no nausea or vomiting.
Client placed in semi-Fowler's position at 45°, feet elevated. Bed in low position. Partner remains at client's bedside.
Diagnostic Results
1700:
Albumin 2.9 g/dL (3.5 to 5 g/dL)
Ammonia 250 mcg/dL (10 to 80 mcg/dL)
Sodium 138 mEq/L (136 to 145 mEq/L)
Potassium 4.8 mEq/L (3.5 to 5 mEq/L)
Fasting glucose 148 mg/dL (70 to 110 mg/dL)
BUN 18 mg/dL (10 to 20 mg/dL)
Creatinine 0.8 mg/dL (0.5 to 1 mg/dL)
Question 4 of 5
The client is exhibiting manifestations of __ due to the client's __
Correct Answer: A
Rationale: The client is experiencing alterations in their level of consciousness and has an elevated ammonia level, indicative of encephalopathy due to liver failure from cirrhosis.
Extract:
Question 5 of 5
A nurse is assessing a client who has diabetes insipidus. Which of the following findings is a manifestation of this diagnosis?
Correct Answer: B
Rationale: Tachycardia can occur in diabetes insipidus due to dehydration and fluid loss.