ATI RN
ATI Advanced Med Surg Final Exam 0924 Questions
Extract:
Question 1 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.
Question 2 of 5
A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Slow, steady bubbling in the suction control chamber may indicate that the suction control pressure needs adjustment.
Extract:
Medical History
Day 1:
Client has a history of emphysema and reports smoking 21 packs of cigarettes per year.
Vital Signs
Day 1:
Temperature 37.6° C (99.7° F)
Blood pressure 114/56 mm Hg
Heart rate 78/min
Respiratory rate 20/min
Pulse oximetry 93% on room air
Day 2:
1000
Temperature 36.9° C (98.4° F)
Blood pressure 88/56 mm Hg
Heart rate 118/min
Respiratory rate 32/min
Pulse oximetry 85% on room air
Diagnostic Results
Day 1:
Chest x-ray shows lung hyperinflation.
Day 2
1000:
Chest x-ray shows right upper lobe pneumothorax.
Nurses' Notes
Day 2:
0800:
Voided 350 mL of clear yellow urine in a bedpan.
1000:
Client reports sudden, sharp, right upper chest pain.
Client appears anxious and states pain increases with deep breathing.
Respirations labored with use of accessory muscles noted.
Crepitus palpated on right upper chest.
Trachea midline, breath sounds decreased in right upper lobe.
Question 3 of 5
For each potential nursing action, click to specify if the action is essential, non-essential, or contraindicated for the client.
| Action | essential | non-essential | contraindicated |
|---|---|---|---|
| Administer an analgesic | |||
| Initiate a weight-based continuous heparin infusion | |||
| Initiate supplemental oxygen | |||
| Prepare client for a chest tube insertion | |||
| Insert an indwelling urinary catheter |
Correct Answer: A,C,D
Rationale: Administer an analgesic is essential for pain management. Initiate supplemental oxygen is essential due to low pulse oximetry. Prepare client for a chest tube insertion is essential to treat the pneumothorax.
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:
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 5 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.
Action to Take
Potential Condition
Parameter to Monitor
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.