ATI RN
ATI RN Adult Medical Surgical 2023 III Questions
Extract:
Question 1 of 5
A nurse is providing teaching about client rights to a client who has a brain tumor. Which of the following client statements indicates an understanding of the teaching?
Correct Answer: A
Rationale: Clients have the right to refuse treatment at any time, reflecting autonomy and understanding of their rights.
Question 2 of 5
A nurse is caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings should the nurse identify as an indication that the medication was effective?
Correct Answer: D
Rationale: Morphine reduces anxiety and preload in heart failure, improving comfort and respiratory effort.
Question 3 of 5
A nurse is assessing a client who sustained major full-thickness burns to their lower legs 12 hr ago. Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: Full-thickness burns cause edema due to vascular leakage and tissue damage within the first 12-24 hours.
Extract:
Patient Summary
Presenting Complaint:
Time of Arrival: 0900 hours
Symptoms: Client reports not feeling well for the past 12 hours, with increasing blood glucose levels. Client has a history of type 1 diabetes mellitus and hypertension. Recent treatment for bronchitis and pneumonia. Reports nausea, decreased appetite, frequent urination, and extreme thirst.
Medical History:
Conditions: Type 1 diabetes mellitus, hypertension.
Recent Illnesses: Bronchitis, pneumonia.
Nurses' Notes
0900 Hours:
Client presents with a history of type 1 diabetes mellitus and hypertension. The client is alert and oriented x4. Heart and lung sounds are clear. The client reports frequent urination, extreme thirst, nausea, and decreased appetite. Bowel sounds are hyperactive in all 4 quadrants. Bilateral pedal pulses are 1+. Slight tenting of skin noted. Peripheral IV established, and labs drawn.
Vital Signs
0900 Hours:
Temperature: 36.8°C (98.2°F)
Pulse Rate: 110/min
Respiratory Rate: 18/min
Blood Pressure: 96/65 mm Hg
Oxygen Saturation: 96% on room air
1400 Hours:
Temperature: 36.8°C (98.2°F)
Pulse Rate: 84/min
Respiratory Rate: 16/min
Blood Pressure: 106/76 mm Hg
Laboratory Results
0915 Hours:
Blood Glucose: 468 mg/dL (Normal: 74-106 mg/dL)
pH: 7.30 (Normal: 7.35-7.45)
Potassium: 5.5 mEq/L (Normal: 3.5-5.0 mEq/L)
Sodium: 138 mEq/L (Normal: 136-145 mEq/L)
Chloride: 101 mEq/L (Normal: 98-106 mEq/L)
BUN: 21 mg/dL (Normal: 10-20 mg/dL)
Creatinine: 1.7 mg/dL (Normal: 0.5-1.1 mg/dL)
Urine Dipstick: Positive for ketones (Normal: Negative)
Provider's Prescriptions
Fluids: Administer 0.9% sodium chloride at 15 ml/kg/hr for 1 hr, then reduce to 10 ml/kg/hr.
Potassium: Potassium chloride 20 mEq/L IV PRN if potassium is less than 5.0 mEq/L.
Insulin: Regular insulin continuous infusion, titrate per DKA protocol once potassium is greater than 3.3 mEq/L.
Anti-nausea: Ondansetron 4 mg IV bolus every 4 hr PRN for nausea.
Pain Relief: Acetaminophen 650 mg every 4 hr PRN for pain.
Magnesium: Magnesium sulfate 2 g IV over 2 hr for hypomagnesemia.
Monitoring: Strict intake and output, blood glucose level hourly.
Question 4 of 5
The nurse should plan to first administer….. followed by……
Correct Answer: D,E
Rationale: Sodium chloride corrects dehydration in DKA, followed by insulin to lower blood glucose.
Extract:
Question 5 of 5
A PACU nurse is monitoring the drainage from a client's NG tube following abdominal surgery. Which of the following findings in the first postoperative hour should the nurse report to the provider?
Correct Answer: B
Rationale: Red drainage indicates active bleeding, a critical finding requiring immediate reporting post-surgery.