ATI RN
ATI SP 250 Exam 3 Med Surg Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is receiving mechanical ventilation and has an ideal weight of 60 kg. The nurse should expect the tidal volume to be set at which of the following?
Correct Answer: B
Rationale: This is because the recommended tidal volume for mechanical ventilation is 6 to 8 mL/kg of ideal body weight.
Therefore, for a client who has an ideal weight of 60 kg, the tidal volume should be between 360 and 480 mL.
Extract:
Nurses' Notes
Vital Signs
Medication
Home health nurse admission note:
Client discharged from healthcare facility yesterday following a 4-day stay for exacerbation of COPD. Lives alone; alert and oriented to person, place, and time. Lung fields with scattered rhonchi throughout, cough productive for thick white sputum, dyspnea with minimal exertion.
Clubbing is noted on fingers, chest is barrel-shaped. Supplemental oxygen at 2L/min via nasal cannula.
Home Health Nurse Note 3 days following discharge from health care facility: Client sleeping in recliner with nasal canula on their lap; awakens easily and is oriented to person but disoriented to place and time.
Lung sounds with scattered rhonchi, cough productive for thick, yellow secretions. 2+pitting edema bilateral in ankles and feet.
Re-oriented client. Client states "I don't remember if I did that breathing machine thing you told me about."
Instructed client on oxygen use, safety, and nebulizer treatments. Elevated lower extremities.
Question 2 of 5
A nurse is caring for a client who has COPD. Select the 5 findings that require follow-up.
Correct Answer: A,C,D,E,F
Rationale: Disorientation may indicate hypoxia, infection, or medication side effects. Yellow sputum may indicate a bacterial infection that requires antibiotics. Nebulizer use may indicate that the client is not using it correctly or regularly as prescribed, which can affect their lung function and oxygenation. Ankle edema may indicate fluid overload or heart failure, which can worsen COPD symptoms and increase the risk of complications. Living alone may pose safety risks for the client, especially if they are disoriented or have difficulty managing their oxygen and nebulizer treatments.
Extract:
Question 3 of 5
A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?
Correct Answer: C
Rationale: This is because central cyanosis reflects a decrease in arterial oxygen saturation and is best seen in areas where blood vessels are close to the surface, such as the oral mucosa, tongue, and lips. Peripheral cyanosis, which may be caused by vasoconstriction or poor circulation, can be seen in the soles of the feet, ear lobes, and nail beds, but it does not necessarily indicate hypoxemia.
Question 4 of 5
A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?
Correct Answer: C
Rationale: This is because central cyanosis reflects a decrease in arterial oxygen saturation and is best seen in areas where blood vessels are close to the surface, such as the oral mucosa, tongue, and lips. Peripheral cyanosis, which may be caused by vasoconstriction or poor circulation, can be seen in the soles of the feet, ear lobes, and nail beds, but it does not necessarily indicate hypoxemia.
Question 5 of 5
A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support?
Correct Answer: C
Rationale: This is because talking with the client can help reduce anxiety, pain, and isolation, as well as build trust and rapport between the nurse and the client. Talking with the client can also provide an opportunity for education, feedback, and encouragement.