ATI RN
ATI Med Surg Woolery Final Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is postoperative following a right radical mastectomy. The client has a Jackson-Pratt (JP) drain in the surgical site. Which of the following assessment findings indicates the JP drain is functioning correctly?
Correct Answer: B
Rationale: A half-full, expanded bulb reservoir with serosanguinous fluid indicates the JP drain is functioning to remove excess fluid from the surgical site.
Question 2 of 5
A client is admitted for an elective transurethral resection of the prostate (TURP). The client is receiving continuous bladder irrigation (CBI) after the procedure. In the post-anesthesia care unit (PACU), the nurse takes the client's vital signs and checks the urinary drainage bag frequently. Which assessment finding should the nurse prioritize reporting to the provider as an indication of a possible complication?
Correct Answer: B
Rationale: Stopped Foley catheter output may indicate a blockage, requiring immediate reporting.
Extract:
Nurses' Notes
0600:
Client was brought to the emergency department by her husband for complaints of abdominal pain 8/10 in all quadrants. Client is alert and oriented x4, states she has had a fever, nausea, and vomiting "off and on" for 2 days. Existing medical conditions include insulin-dependent type-2 diabetes, hypertension, and end-stage renal disease. Abdomen assessed, found to be rigid and distended. Rebound tenderness noted on palpation. Bowel sounds auscultated, hyperactive in all quadrants. Catheter present in abdominal wall, currently clamped. Client states "I do my own dialysis every day. Yesterday the effluent was cloudy. I haven't done an exchange yet today." STAT BMP and CBC have resulted. Physician notified. Awaiting orders.
Vital Signs
0600:
Temperature: 39.1°C (102.3°F)
Pulse rate: 110/min
Respiratory rate: 24/min
Blood pressure: 123/70 mmHg
Oxygen saturation: 95% room air
Laboratory results
0600:
BMP:
Creatinine: 3.8 mg/dL
Glucose: 180 mg/dL
Potassium: 5.4 mEq/L
Sodium: 134 mEq/L
BUN: 68 mg/dL CBC:
WBC: 15,000/mm3
RBC: 4.3 x 10/μL
Platelets: 250,000/μL
Hemoglobin: 12 g/dL
Hematocrit: 39%
Question 3 of 5
The client is experiencing...... caused by.....
Correct Answer: A,B
Rationale: Peritonitis is indicated by abdominal pain, fever, and cloudy dialysis effluent, caused by peritoneal dialysis.
Extract:
Question 4 of 5
A nurse is caring for a client who is receiving warfarin for atrial fibrillation. The client's INR is 4.5. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: An INR of 4.5 is too high, indicating increased bleeding risk; vitamin K can help reverse warfarin's effects.
Question 5 of 5
A nurse is caring for a client who has a diagnosis of Cushing syndrome. After performing magnetic resonance imaging (MRI), the underlying cause of the condition is found to be hyperplasia of the adrenal glands. Which of the following lab results would the nurse anticipate with this condition?
Correct Answer: C
Rationale: Low ACTH and elevated cortisol is consistent with Cushing syndrome caused by adrenal gland hyperplasia, where the adrenal glands produce excess cortisol independently of ACTH stimulation.