ATI RN
ATI Advanced Med Surg Final Exam 0924 Questions
Extract:
Medical History
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."
Nurses' Notes
Client appears anxious and tachypneic. Respirations are labored and shallow. Lung sounds absent in the right lower lobe. Skin is cool and slightly cyanotic.
Vital Signs
Temperature 36.2° C (98.4° F) Pulse 120/min; regular
Respiratory rate 38/min
Blood pressure 92/64 mm Hg
O saturation 85% on room air
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 | |||
| Thoracentesis | |||
| Pulmonary Function Tests (PFTS) | |||
| Prepare for insertion of a chest tube | |||
| Obtain ABGS | |||
| Computed tomography (CT) of the chest |
Correct Answer: A,D,E,F
Rationale: IV access, chest tube insertion, ABGs, and CT of the chest are anticipated to manage and diagnose the extent of the pneumothorax.
Extract:
Question 2 of 5
A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?
Correct Answer: D
Rationale: A distended bladder is a common trigger for autonomic dysreflexia in clients with a spinal cord injury at or above T-6, making it a key indicator for monitoring.
Extract:
Physical Examination
0800:
Alert and oriented to person and place
Skin pale and dry
Pupils equal, round, and reactive to light and accommodation Mucous
membranes moist and pink
Heart sounds regular and moderate
Peripheral pulses moderate
Capillary refill 3 seconds
Lungs sounds clear to auscultation bilaterally
Respirations labored at rest
Abdomen soft and nontender, active bowel sounds x 4 quadrants
No peripheral edema
Reports slight midsternal chest pain, rates pain as a 2 on a 0 to 10 pain scale
States they have been weak for the past 4 months with dizziness. Denies dizziness at this time.
1300
Returns to room after insertion of permanent pacemaker Alert and oriented to person, needs cues for time and place
Skin cool and dry
Heart sounds regular, heart rate 72/min
Lung sounds are coarse bilaterally
Hyperresonance noted upon percussion of chest wall
Respiratory rate 24/min and slightly labored
Oxygen saturation 2 U/min per nasal cannula 98%
Reports slight incisional pain left upper chest area
Small amount red drainage present on dressing over incisional site
Diagnostic Results
RBC count 5.2 million/mm3 (4.7 to 6.1 million/mm3) WBC count 7,000 mm (5,000 to 10,000 mm3)
Hemoglobin 15.4 g/dL (14 to 18 g/dL)
Hematocrit 48% (42% to 52%)
Platelets 250,000/mm3 (150,000 to 400,000/mm3)
Basic Metabolic Profile:
BUN 18 mg/dL (10 to 20 mg/dL)
Creatinine 1.0 mg/dL (0.6 to 1.3 mg/dL)
Total Calcium 9.5 mg/dL (9.0 to 10.5 mg/dL)
Carbon Dioxide 27 mEq/L (23 to 30 mEq/L) Chloride 101 mEq/L (98 to 106 mEq/L) Glucose 80 mg/dL (74 to 106 mg/dL) Potassium 5.1 mEq/L (3.5 to 5 mEq/L) Sodium 140 mEq/L (136 to 145 mEq/L)
Vital Signs
Temperature 36 Cm
Apical pulse 42min
Respiratory rate 25/min
Blood pressure 106/58 mm Hg
Oxygen saturation 54% on room air
Question 3 of 5
The nurse is caring for the client immediately following the insertion of the permanent pacemaker.Complete the following sentence by using the list of options. The nurse should monitor the client for __ and __ following permanent pacemaker placement.
Correct Answer: A,B
Rationale: Monitoring for incisional site bleeding ensures no complications like hematoma. Bradycardia monitoring ensures the pacemaker is functioning correctly.
Extract:
Question 4 of 5
A nurse is caring for a client who is postoperative following an open reduction internal fixation (ORIF) of a femur fracture. Which of the following parameters should the nurse include in the evaluation of the neurovascular status of the client's affected extremity? (Select all that apply.)
Correct Answer: B,C,D,E
Rationale: Skin integrity, temperature, color, and sensation are all critical parameters for assessing neurovascular status to detect complications like impaired circulation or nerve damage.
Question 5 of 5
A nurse is preparing to administer 0.45% sodium chloride (NaCl) 2000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 250
Rationale:
Total volume of IV fluid: 2000 mL.
Total time for infusion: 8 hours. Infusion rate: 2000/8 = 250 mL/hr.