ATI RN
ATI Medical Surgical 2 Final 2024 Assessment Questions
Extract:
Question 1 of 5
A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer and who has neutropenia. The nurse should include which of the following restrictions in the client's plan of care?
Correct Answer: D
Rationale: Fresh flowers and potted plants should be avoided in the room of a neutropenic patient. They can harbor fungi and other microorganisms that could cause infection in an immunocompromised individual. Neutropenic precautions typically include avoiding standing water and plants that may contain harmful bacteria or fungi.
Question 2 of 5
A nurse is assessing a client who has intravenous therapy-related phlebitis. The nurse uses the Infusion Nurses Society's phlebitis scale to assess the severity of phlebitis and documents the client's phlebitis as grade level 1. Which of the following assessment findings correlates with a grade level of 1?
Correct Answer: B
Rationale: Redness at the IV site with pain corresponds to grade 1 phlebitis on the Infusion Nurses Society's scale, indicating mild erythema and possible pain. Purulent drainage, red streaks, and a palpable venous cord indicate more severe grades (2-4).
Question 3 of 5
A nurse has received a report on a group of clients. Which of the following clients should the nurse assess first?
Correct Answer: D
Rationale: A client with a stroke reporting severe headache and confusion may have increased intracranial pressure or hemorrhage, requiring immediate assessment.
Question 4 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: D
Rationale: Instructing the client to wiggle his toes is a direct assessment of motor function, a key component of neurovascular status, helping to determine if there is any impairment in nerve function or blood supply to the affected area.
Question 5 of 5
During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest. The lesion is raised and flesh-colored with pearly white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer?
Correct Answer: B
Rationale: Malignant melanoma typically presents as a mole that changes in color, size, or feel and has irregular edges. It may also itch, ooze, or bleed. A raised, flesh-colored lesion with pearly white borders is not characteristic of malignant melanoma. Basal cell carcinoma often appears as a raised, pearly bump, sometimes with visible blood vessels, which may have a central depression. The description of the lesion as raised, flesh-colored with pearly white borders aligns with the common presentation of basal cell carcinoma. Squamous cell carcinoma usually presents as a firm, red nodule, or a flat lesion with a scaly, crusted surface. The lesion described does not match the typical appearance of squamous cell carcinoma. Actinic keratosis is characterized by rough, scaly patches on sun-exposed areas of the skin, which may be precancerous. They are not typically described as raised, flesh-colored lesions with pearly borders.