ATI RN
ATI Med Surg 2 Respiratory exam Questions
Extract:
Question 1 of 5
A nurse is planning care for a client who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan? (Select all that apply.)
Correct Answer: A,B,D
Rationale: Implementing a low-sodium diet helps reduce fluid retention and ascites. Furosemide is a diuretic that reduces fluid overload. Measuring abdominal girth monitors ascites progression. Warfarin increases bleeding risk, and weight lifting can exacerbate varices.
Question 2 of 5
A nurse is caring for a child who has Addison's disease. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Teaching the parents about cortisol replacement therapy is essential in Addison's disease management, as cortisol deficiency is the primary issue.
Question 3 of 5
A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan?
Correct Answer: D
Rationale: Placing the client in a prone position has been shown to improve oxygenation in ARDS by enhancing lung expansion and ventilation-perfusion matching.
Extract:
History and Physical
The client has a history of coronary artery disease, type 2 diabetes mellitus, renal failure, and had a renal transplant 6 weeks ago. The client reports worsening fatigue over the last 3 days and loss of appetite but denies nausea or vomiting.
Vital Signs
• Blood pressure: 180/90 mm Hg
• Heart rate: 105/min
• Temperature: 37.1° C (98.8° F)
• Respirations: 18/min, labored
• Pulse oximetry: 94% on 2L nasal cannula
Nurses Notes
The client appears pale on assessment. Lung and heart sounds are within defined limits. The abdomen is tender in the area of the incision from the transplant. Bowel sounds are hypoactive in all four quadrants. Bilateral pedal pulses are +2. The client has +1 edema in bilateral lower extremities. The client reports urinating only twice per 24-hour period for the last 2 days
Diagnostic Results
• BUN: 25 mg/dL (10 to 20 mg/dL)
• Creatinine: 2.0 mg/dL (0.5 to 1.3 mg/dL)
• Hemoglobin: 15 mmol/L (12 to 18 mmol/L)
• Hematocrit: 45% (37% to 52%)
• Potassium: 5.2 mEq/L (3.5 to 5.0 mEq/L)
• Sodium: 145 mEq/L (136 to 145 mEq/L)
Physical Examination Results
The incision site on the abdomen is tender to touch, with mild redness and swelling. The client has bilateral pedal pulses that are +2 and exhibits +1 edema in both lower extremities. The client’s bowel sounds are hypoactive in all four quadrants. The client appears pale, and reports urinating only twice per day for the last 2 days
Question 4 of 5
A nurse is caring for a 65-year-old male client who is admitted to the emergency department for fatigue. Which of the following findings indicate that the client may be experiencing transplant rejection? (Select all that apply)
Correct Answer: A,B,C
Rationale: Tenderness, redness, and swelling at the incision site, edema in the lower extremities, and elevated blood pressure can indicate transplant rejection.
Extract:
Question 5 of 5
A nurse is assessing a client who has an infection. Which of the following findings is a manifestation of sepsis? (Select all that apply.)
Correct Answer: C,D,E
Rationale: Altered mental status, elevated WBC count, and vomiting are manifestations of sepsis due to systemic inflammation and infection response. Hypertension and hypoglycemia are not typical.