ATI RN
ATI Nurs285 Med Surg Exam Questions
Extract:
Medical History
Nurses' Notes
Vital Signs
Client reports an injury to their right ribs after falling 6 feet from a ladder. Client reports pain as 8 on a scale of 0 to 10 over the right lower rib cage with ecchymosis. Client is dyspneic and respirations are shallow. Client states, "It's hard for me to breathe."
Question 1 of 5
A nurse is reviewing the client's medical record. Which of the following prescriptions should the nurse anticipate for a client who has a pneumothorax? For each potential provider's prescription, click to specify if the potential prescription is anticipated, non-essential, or contraindicated for the client.
| Options | Anticipated | Non- essential | Contraindicated |
|---|---|---|---|
| Obtain intravenous access: Anticipated | |||
| Computed tomography (CT) of the chest: Anticipated | |||
| Thoracentesis: Non-essential | |||
| Obtain ABGs (Arterial Blood Gases): Anticipated | |||
| Pulmonary Function Tests (PFTs): Contraindicated | |||
| Prepare for insertion of a chest tube: Anticipated |
Correct Answer: A,B,D,F
Rationale: IV access, CT chest, ABGs, and chest tube insertion are anticipated for pneumothorax management. Thoracentesis is non-essential as it addresses fluid, not air. PFTs are contraindicated in acute settings.
Extract:
Question 2 of 5
A 70-year-old client in a nursing home is found wandering in the hall and has a new onset confusion. Which action should the registered nurse implement first?
Correct Answer: D
Rationale: Assessing the client's lung fields and temperature is the first priority because new onset confusion in an older adult is often a symptom of an underlying medical issue, such as infection or hypoxia. Early assessment helps identify the cause and guide appropriate interventions.
Question 3 of 5
The nurse is caring for a patient with a long history of chronic obstructive pulmonary disease (COPD) who develops cor pulmonale. The nurse should monitor the patient for which expected finding if heart failure is present?
Correct Answer: C
Rationale: Peripheral edema is a key sign of right-sided heart failure in cor pulmonale, resulting from fluid accumulation due to impaired cardiac pumping.
Question 4 of 5
Which assessment data would warrant immediate intervention by the nurse?
Correct Answer: C
Rationale: Pain on inspiration in a client with deep vein thrombosis may indicate a pulmonary embolism, a life-threatening condition requiring immediate assessment and intervention.
Question 5 of 5
A client suffered a fractured femur and is scheduled for surgery one day after sustaining the injury. The client develops acute respiratory distress syndrome (ARDS) and the healthcare provider suspects fat embolism (FES) based on which of the following clinical manifestations? (Select all that apply.)
Correct Answer: A,C,D
Rationale: Decreased PaO2 <60mmHg, decreased platelet count and hematocrit, and ECG changes (ST segment and T-wave) are clinical manifestations of fat embolism syndrome, indicating hypoxemia, DIC, and myocardial effects.