ATI RN
ATI Advanced Med Surg Final Exam 0924 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions?
Correct Answer: B
Rationale: Defibrillation is used for pulseless ventricular tachycardia or ventricular fibrillation to restore a normal heart rhythm.
Question 2 of 5
A nurse is preparing to administer clindamycin 300 mg by intermittent IV bolus over 30 min to a client who has a staphylococci infection. Available is clindamycin premixed in 50 ml. 0.90% sodium chloride (NaCl). The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: B
Rationale: First, calculate the total volume to be infused over the desired time frame: 50 mL over 30 minutes.
To find the rate in mL/hr, multiply the volume by 2 (since 30 minutes is half an hour), resulting in 100 mL/hr.
Question 3 of 5
A nurse is preparing a client who is scheduled to undergo a paracentesis. Into which of the following positions should the nurse assist the client for this procedure?
Correct Answer: C
Rationale: High-Fowler's position helps pool the ascitic fluid in the lower abdomen, making it easier to access and drain during the procedure.
Extract:
Nurses' Notes
Day 1:
0900:
Client admitted from emergency department with hemoptysis, dull chest pain, increasing fatigue, anorexia, nausea, chest tightness, and 3.2 kg (7 lb) weight loss in 2 weeks. Heart rate regular, lung sounds with crackles in bilateral upper lobes. No edema. Airborne precautions initiated upon admission.
Day 2:
1100:
Client reports shortness of breath, nausea, and fatigue. Crackles auscultated bilaterally throughout lung fields. Productive cough, with thick, blood-streaked sputum. Bowel sounds active, no edema.
Day 3:
0900:
Client reports some improvement in dyspnea. Client coughing up thick, yellow, blood-streaked sputum. Crackles auscultated in bilateral upper lobes of lungs. Sclera noted to be yellow. Client’s weight is 0.7 kg (1.6 lb) less than at admission. Encouraged to increase intake of oral fluids. Client reports urine appears reddish orange in color.
Medical history
Client has no chronic illnesses. Traveled out of the country 2 months ago.
Vital Signs
Day 1:
Temperature 38.6°C (101.4°F)
Heart rate 96/min
Respiratory rate 26/min
Blood pressure 158/88 mm Hg
Oxygen saturation 91% on room air
Day 2:
Temperature 38.4°C (101.2°F)
Heart rate 88/min
Respiratory rate 24/min
Blood pressure 152/82 mm Hg
Oxygen saturation 92% on 02 at 4L/min via nasal cannula
Day 3:
Temperature 37.8°C (100.1°F)
Heart rate 82/min
Respiratory rate 22/min
Blood pressure 130/78 mm Hg
Oxygen saturation 96% on 02 at 4L/min via nasal cannula
Provider prescriptions
Day 1:
Purified protein derivative 0.1 mL intradermal to right forearm
Isoniazid 300 mg PO daily
Rifampin 600 mg PO daily
Acetaminophen 500 mg 1-2 tablets PO every 4 to 6 hr PRN fever, pain
Diagnostic Results
Day 1
ALT 36 SI/L (4-36 SI/L)
AST 35 units/L (0-35 units/L)
Alkaline phosphatase 118 units/L (30-120 units/L)
Chest x-ray caseation with inflammation throughout upper lobes
Day 3:
Mantoux Test: 12 mm induration (negative, reaction less than 5 mm) ALT 38 SI-36 SI/L)
AST 36 units/L (0-35 units/L)
Alkaline phosphatase 129 units/L (30-120 units/L)
Question 4 of 5
A nurse on a medical-surgical unit is caring for a newly admitted client with a diagnosis of R/O tuberculosis. Which of the following findings should the nurse report to the provider?
Correct Answer: A
Rationale: Yellow sclera indicates jaundice, which could be a sign of liver dysfunction, especially concerning given the client is on isoniazid and rifampin, which can cause hepatotoxicity.
Extract:
Question 5 of 5
A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status?
Correct Answer: C
Rationale: Instructing the client to wiggle his toes assesses motor function and circulation to the distal extremities, which are crucial for neurovascular status.