ATI RN
ATI Nur258 Med Surg 2 Final Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority?
Correct Answer: B
Rationale: Suctioning saliva from the client's mouth is the highest priority because an unconscious client is at risk for airway obstruction due to the accumulation of saliva or other secretions. Maintaining a clear airway is essential to prevent aspiration and ensure adequate oxygenation.
Question 2 of 5
A nurse is teaching a female client with systemic lupus erythematosus (SLE) about exacerbating factors for their disease. Which statement about exacerbating factors by the client requires further teaching?
Correct Answer: A
Rationale: The statement about keeping the temperature cold to avoid becoming overheated requires further teaching. While avoiding excessive heat is important for individuals with SLE, maintaining an overly cold environment can also trigger symptoms, as cold temperatures can lead to vasoconstriction and Raynaud's phenomenon, which is common in SLE patients.
Question 3 of 5
A client arrives in the emergency department with an ischemic stroke. What is the priority for the nurse to assess in relation to the administration of tissue plasminogen activator (t-PA) as treatment?
Correct Answer: A
Rationale: Current anticoagulant use is crucial to assess before administering t-PA because combining t-PA with anticoagulants can significantly increase the risk of bleeding complications. It is essential to ensure that the client is not on medications that could interact adversely with t-PA.
Extract:
Nurses' Notes
Family member brought client to the ED for pain in left arm that began last evening. Client has a history of sickle cell disease diagnosed at age 4 years. Client has prescription for oral morphine sulfate and took one dose last evening at 1800 and this morning at 0900. Client reports no relief from pain, reporting it as 9 on a scale of 0 to 10.
Physical Examination
Client appears in moderate distress, reporting throbbing and stabbing pain to the left arm and hand. Client has full range of motion to arm, wrist, and fingers but resists movement due to pain. Capillary refill is less than 2 seconds, skin warm and dry, no edema, no rashes, no lesions. Client has used oral morphine sulfate in the past to alleviate pain. Reports taking dose of morphine sulfate last night at 1800 with no relief. Took an additional dose of morphine sulfate at 0900 this morning and states, "I am in still in pain, the morphine didn't work." Heart rate regular with no murmur, lungs clear, abdomen soft and nontender.
Vital Signs
Blood pressure 114/68 mm Hg
Heart rate 98/min
Respiratory rate 18/min
Temperature 37.1° C (98.9° F)
SpO2 95% on room air
Question 4 of 5
For each potential healthcare provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.
| Options | Anticipated | Nonessential | Contraindicated |
|---|---|---|---|
| Intravenous fluid administration | |||
| Ice packs to affected area 15 min on/15 min off | |||
| Ambulation in hallway with supervision | |||
| Hydromorphone intravenously (IV) for pain | |||
| Acetaminophen orally (PO) for pain | |||
| Oxygen 2 L/min via nasal cannula |
Correct Answer: A,D
Rationale: Intravenous fluid administration is anticipated to reduce viscosity of sickled cells. Hydromorphone IV is anticipated for severe pain unresponsive to oral morphine.
Extract:
Question 5 of 5
A nurse is teaching a female client with systemic lupus erythematosus (SLE) about exacerbating factors for their disease. Which statement about exacerbating factors by the client requires further teaching?
Correct Answer: A
Rationale: The statement about keeping the temperature cold to avoid becoming overheated requires further teaching. While avoiding excessive heat is important, maintaining an overly cold environment can also trigger symptoms, such as Raynaud's phenomenon, which is common in SLE patients. Proper temperature regulation, rather than extremes, is essential.