ATI RN
ATI Nur258 Med Surg 2 Final Exam Questions
Extract:
Question 1 of 5
A nurse is planning care for a client who is 2 hours postoperative following a transurethral resection of the prostate. The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include?
Correct Answer: D
Rationale: Reminding the client that he might feel a constant urge to void is essential. Continuous bladder irrigation can cause bladder spasms and a persistent sensation of needing to urinate, which is common after TURP. This helps the client understand and cope with these sensations, reducing anxiety and unnecessary concern.
Question 2 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.
Question 3 of 5
A diabetes nurse educator is discussing 'sick day rules' with a client newly diagnosed with diabetes mellitus type 1. Which statement by the client indicates a need for further teaching?
Correct Answer: B
Rationale: It is crucial for clients with diabetes to continue taking insulin during illness, even if they are unable to eat. Insulin needs may increase due to stress or infection, and not taking insulin could lead to hyperglycemia or diabetic ketoacidosis. Checking blood sugar every 2 hours is correct, but insulin should not be omitted.
Extract:
History and Physical
Day 1
Client works as a firearms instructor at a shooting range.
Hypertension
Heart failure
Osteoarthritis
Medication Administration Record
Day 1:
Gentamycin 500 mg by mouth (PO) daily
Bumetanide 2 mg PO daily
Naproxen 250 mg PO daily
Nurses' Notes
6 months later:
Client reports having trouble hearing in noisy places.
Client states they are hearing sounds as muffled.
Diagnostic Results
6 months later:
Audiometer test with hearing loss at 39 dB
Question 4 of 5
A nurse is reviewing a client's medical record. Select the 4 findings that place the client at risk for hearing impairment.
Correct Answer: B,C,D,E
Rationale: Employment at a shooting range, gentamycin, naproxen, and bumetanide are risk factors for hearing impairment due to noise exposure and ototoxicity.
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 5 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.