ATI RN
ATI Advanced Med Surg Final Exam 0924 Questions
Extract:
Question 1 of 5
A nurse is planning postoperative care for a client who is scheduled for an ileal conduit procedure. The nurse should include which of the following in the client's plan of care? (Select all that apply.)
Correct Answer: A,C,D
Rationale: Hematuria is expected following an ileal conduit procedure. Monitoring hourly urine output ensures patency of the urinary system. Applying a skin barrier around the stoma site prevents skin breakdown.
Extract:
Nurse's Notes
Client admitted to the unit for a lower GI bleed. Continues to have frequent bloody stools and is scheduled for a lower endoscopy in 4 hr. The client is receiving their fourth unit of packed red blood cells (packed RBCs). Unit of fourth packed RBCS started at a rate of 250 cc/hr. Thirty minutes after the transfusion started, client started reporting dyspnea and restlessness. Crackles auscultated in bilateral lower lobes. oxygen saturation 92% on 2L nasal cannula, and jugular vein distension noted.
Vital Signs
Temperature 37.3" (99.1" F)
Blood pressure 189/90 mm Hg
Pulse rate 100/min
Respiratory rate 28/min
Question 2 of 5
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
Correct Answer: B,C
Rationale: The client's symptoms are consistent with TACO. Administer furosemide to reduce fluid overload and diphenhydramine for possible mild allergic reaction. Monitor intake and output and weight to assess fluid balance.
Extract:
Question 3 of 5
A nurse is providing teaching for a client who is scheduled for a myelogram. Which of the following statements indicates the client understands the teaching?
Correct Answer: D
Rationale: Keeping the head elevated after a myelogram helps prevent headaches and other complications from the procedure.
Extract:
Vital Signs:
1500:
Temperature 37.3° C (99.1° F)
BP 154/64 mm Hg
Heart rate 105/min
Respiratory rate 26/min
Oxygen saturation 93% on room air
Medical History
Cirrhosis
Hypertension, controlled with metoprolol therapy
Type 2 diabetes mellitus, controlled with glipizide therapy
Physical Examination
1500:
Client presents with decreased level of consciousness, slurred speech, and impaired concentration. Client is lethargic, does not respond to questions or simple commands. Pupils round, reactive to light and accommodation. Partner states client has been sleeping during the day and remains awake at night.
Skin is dry and jaundiced with petechiae present to arms and legs.
S1 S2 heard on auscultation. +1 pulses on bilateral radial and pedal pulses. Peripheral edema +3 present in bilateral lower extremities.
Crackles auscultated in bilateral lower lobes.
Abdomen distended with ascites. Hypoactive bowel sounds present in all four quadrants. Partner reports no knowledge of rectal bleeding, states client has been tolerating diet with no nausea or vomiting.
Client placed in semi-Fowler's position at 45°, feet elevated. Bed in low position. Partner remains at client's bedside.
Diagnostic Results
1700:
Albumin 2.9 g/dL (3.5 to 5 g/dL)
Ammonia 250 mcg/dL (10 to 80 mcg/dL)
Sodium 138 mEq/L (136 to 145 mEq/L)
Potassium 4.8 mEq/L (3.5 to 5 mEq/L)
Fasting glucose 148 mg/dL (70 to 110 mg/dL)
BUN 18 mg/dL (10 to 20 mg/dL)
Creatinine 0.8 mg/dL (0.5 to 1 mg/dL)
Question 4 of 5
The client is exhibiting manifestations of __ due to the client's __
Correct Answer: A
Rationale: The client is experiencing alterations in their level of consciousness and has an elevated ammonia level, indicative of encephalopathy due to liver failure from cirrhosis.
Extract:
Question 5 of 5
A nurse is reviewing the laboratory findings for a client who has idiopathic thrombocytopenic purpura (ITP). Which of the following findings should the nurse expect to be decreased?
Correct Answer: D
Rationale: Platelets are expected to be decreased in ITP, which is characterized by an immune-mediated destruction of platelets.