ATI RN
ATI Advanced Med Surg Exam 4 Questions
Extract:
Question 1 of 5
A nurse is helping to triage a group of clients at a mass casualty incident who were involved in an explosion at a local factory. Which of the following clients should the nurse tag to be the priority for care?
Correct Answer: C
Rationale: A hissing chest wound indicates a life-threatening tension pneumothorax requiring immediate care.
Extract:
Physical Examination
January:
Weight 70.5 kg (155 lb)
BMI 24
February:
Weight 69 kg (152 lb)
BMI 23
Diagnostic Results
January:
Complete Blood Count:
RBC count 4.2 (4.2 to 5.4)
WBC count 5,500/mm3 (5,000 to 10,000/mm3)
Hgb 12 g/dl (12 g/dL to 16 g/dL)
Het 37% (37% to 47%)
Platelet count: 150,000/mm2 (150,000 to 400,000/mm
February:
Complete Blood Count
WBC count: 4,500/mm2 (5,000 to 10.000/mm3)
RBC count 4 (4.2 to 5.4)
Hgb: 14 g/dL (15 g/dl to 16 g/dl
Het 36 (376 to 4796)
Platelet count: 140,000/mm(150.000 to 400,000/mm3)
Nurses' Notes
January:
Client reports fatigue and nausea following chemotherapy treatments. States, "It just makes me not want to eat. When I do eat, the food taste funny."
Client teaching: Instructed client to attempt to eat small meals several times daily, to eat food cold or at room temperature, to avoid fried foods. Encourage client to rest before eating meals.
Oral mucosa is inflamed.
Client teaching: Instructed client to avoid mouthwashes that contain alcohol, to increase water intake to 2 or more liters daily, and to avoid hot foods.
Reviewed laboratory findings and stressed the need to protect self from illness due to immunosuppression.
Client teaching: Instructed client to not eat raw or undercooked meat, to drink only pasteurized milk, and to boil water before drinking it take temperature daily and report fever, avoid crowds, wash hands frequently with antimicrobial soap.
Reviewed laboratory findings and stressed need for bleeding precautions. Client states, "I’ve had bleeding from these ulcers in my mouth.”
Client teaching Use an electric razor take a stool softener if constipation occurs, avoid coarse-textured foods.
February
Client has experienced weight loss of 1.5 kg (3 B), has experienced decrease in hct and high, WBC and platelet count.
Client reports still not able to consume much food has increased intake
of water. Oral mucosa with less inflammation.
Client reports no bleeding episodes.
Question 2 of 5
A nurse is caring for a client who has cancer and is undergoing chemotherapy. Which of the following assessments indicates an improvement in the client's condition? (Select all that apply.)
Correct Answer: A,C,D
Rationale: A: A decrease in WBC count may indicate reduced chemotherapy-induced immunosuppression. C: Absence of bleeding episodes suggests improved mucosal integrity. D: Reduced oral inflammation indicates effective interventions. E: Weight loss does not indicate improvement.
Extract:
Question 3 of 5
A nurse in an emergency department is assessing a client who was bitten on the left leg by a poisonous snake. The client has placed elastic bandages snuggly above and below the bite marks and is in no apparent distress. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: Obtaining anti-venom is critical to prevent systemic effects of venom.
Question 4 of 5
A client is receiving treatment for stage IV ovarian cancer and asks the nurse to discuss her prognosis. The client plans to have aggressive surgical, radiation, and chemotherapy treatments. Which of the following prognoses should the nurse discuss with the client?
Correct Answer: A
Rationale: A guarded prognosis reflects uncertainty due to advanced disease and treatment intensity.
Question 5 of 5
An unresponsive 79-yr-old patient is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 105.4° F (40.8° C), blood pressure (BP) is 88/50 mm Hg, and pulse is 112 beats/min. What action should the nurse plan to take?
Correct Answer: C
Rationale: Applying wet sheets and a fan rapidly lowers core temperature to prevent organ damage.