ATI RN
ATI Medical Surgical 2 Final 2024 Assessment Questions
Extract:
Question 1 of 5
A nurse is caring for a group of critically ill clients. Which of the following clients are exhibiting potential manifestations of sepsis? (Select all that apply)
Correct Answer: B,C
Rationale:
Choice A: A temperature of 37.2°C (99°F) is slightly elevated but not necessarily indicative of sepsis. A heart rate of 88/min is within normal limits (60-100/min). This client's signs do not strongly suggest sepsis.
Choice B: A heart rate of 132/min and a respiratory rate of 30/min are both elevated, which can be signs of sepsis. Sepsis can cause an increase in heart rate (tachycardia) and respiratory rate (tachypnea) as the body attempts to maintain adequate blood flow and oxygenation during a systemic infection.
Choice C: A decrease in the level of consciousness combined with a heart rate greater than 130/min could indicate sepsis, as confusion or changes in mental status are common symptoms when the body is fighting a severe infection.
Choice D: Bradypnea, or abnormally slow breathing, is not typically associated with sepsis, which more commonly causes rapid breathing. A WBC count of 10,000/mm^3 is at the upper limit of the normal range and does not necessarily indicate sepsis without other symptoms.
Choice E: A temperature of 36°C (96.8°F) is on the lower end of the normal body temperature range and does not suggest fever, which is a common sign of sepsis. A respiratory rate of 16/min is within the normal range (12-20/min) and does not indicate sepsis.
Question 2 of 5
A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.)
Correct Answer: B,C
Rationale: Minimizing moisture and elevating heels prevent skin breakdown; massaging red areas, 4-hour turning, and powder use are inappropriate.
Question 3 of 5
A nurse is teaching a client who has a pelvic fracture about the manifestations of fat embolism syndrome. The nurse should include which of the following findings as an early manifestation?
Correct Answer: C
Rationale: Tachypnea, or rapid breathing, is an early manifestation of fat embolism syndrome. This condition occurs when fat globules are released into the bloodstream, often following a fracture, and can obstruct pulmonary vessels, leading to respiratory distress. Tachypnea is a critical early sign as the body attempts to compensate for reduced oxygenation.
Question 4 of 5
A nurse is assessing a client who reports a nevus that has increased in size and an irregularly shaped lesion that varies in color. These findings are consistent with which of the following medical diagnoses?
Correct Answer: B
Rationale: Malignant melanoma is characterized by changing nevi with size increase and color variation.
Question 5 of 5
A nurse is providing breast self-examination teaching to a client who is menopausal. Which of the following statements should the nurse identify as an indication that the teaching was effective? (Select all that apply.)
Correct Answer: A,B,C,E
Rationale:
Choice A: This statement is correct because the underarm area (axilla) contains lymph nodes that can be affected by breast cancer. Including the underarm area in a breast self-exam helps in detecting any unusual lumps or changes that could indicate a problem.
Choice B: This statement is correct because using firm pressure during a breast self-exam helps to feel the deeper tissues of the breast, which is essential for detecting any abnormalities or lumps that might be present.
Choice C: This statement is correct because performing a breast self-exam in the shower is a common and effective method. The wet and slippery skin makes it easier to feel for any changes or lumps in the breast tissue.
Choice D: This statement is incorrect because it is normal to feel a firm ridge in the lower curve of the breast. This ridge is part of the normal breast anatomy and does not necessarily indicate a problem.
Choice E: This statement is correct because menopausal women do not have menstrual cycles to guide the timing of their breast self-exams.
Therefore, they can choose any consistent day each month to perform the exam.