ATI RN
ATI Medical Surgical 2 Final 2024 Assessment Questions
Extract:
Question 1 of 5
A nurse is preparing a client for surgery. Which of the following is a priority when completing an assessment preoperatively?
Correct Answer: C
Rationale: Identifying possible surgical risks is the priority in a preoperative assessment to plan safe surgical care and make informed decisions about proceeding with the surgery.
Question 2 of 5
Which of the following statements about HIPAA indicates a need for further teaching?
Correct Answer: C
Rationale: The statement 'Information about a client can be disclosed to family members at any time' is incorrect. Under HIPAA, protected health information can only be disclosed to family members under specific conditions, such as with patient permission or when relevant to their involvement in the patient's care.
Question 3 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.
Question 4 of 5
A nurse is assessing a client who is being admitted from the Post-Anesthesia Care Unit (PACU) following an abdominal hysterectomy. Which of the following assessments is the nurse's priority?
Correct Answer: B
Rationale: Oxygen saturation is the priority to ensure adequate oxygenation post-anesthesia, preventing respiratory complications.
Question 5 of 5
A nurse is caring for a client who has type 1 diabetes mellitus. The nurse misread the client's morning blood glucose level as 210 mg/dL instead of 120 mg/dL and administered the insulin dose appropriate for a reading over 200 mg/dL before the client's breakfast. Which of the following actions is the nurse's priority?
Correct Answer: A
Rationale: When a nurse administers an incorrect insulin dose, the immediate concern is the risk of hypoglycemia, especially since the insulin dose given was for a higher blood glucose level than the actual reading. Hypoglycemia can occur when blood glucose levels drop below 70 mg/dL. Symptoms of hypoglycemia include shakiness, sweating, confusion, and in severe cases, loss of consciousness. Monitoring the client for hypoglycemia allows the nurse to detect and treat it promptly, ensuring the client's safety. While completing an incident report is important for documenting the medication error and preventing future occurrences, it is not the immediate priority. The nurse's first responsibility is to ensure the client's safety by addressing the potential hypoglycemia. Once the client's condition is stable, the nurse can then complete the incident report. Administering 15 to 20 grams of carbohydrate is a treatment for hypoglycemia. However, this action should only be taken if the client is actually experiencing hypoglycemia. The nurse should first monitor the client's blood glucose levels to confirm hypoglycemia before administering carbohydrates. Notifying the nurse manager is important for accountability and to ensure that appropriate follow-up actions are taken. However, it is not the immediate priority. The nurse should first monitor the client for hypoglycemia and address any immediate health concerns before notifying the nurse manager.