ATI RN
ATI Medical Surgical 2 Final 2024 Assessment Questions
Extract:
Question 1 of 5
A nurse is teaching a group of teenage clients about the use of condoms for the prevention of sexually transmitted infections (STIs). Which of the following statements should the nurse include in the teaching?
Correct Answer: B
Rationale: Female condoms are effective in preventing the transmission of sexually transmitted viruses, including HIV, by acting as a barrier to prevent the exchange of bodily fluids during sexual activity. This information empowers individuals with an additional option for protection.
Question 2 of 5
A nurse is caring for a group of critically ill clients. Which of the following clients are exhibiting potential manifestations of sepsis? (Select all that apply)
Correct Answer: B,C
Rationale:
Choice A: A temperature of 37.2°C (99°F) is slightly elevated but not necessarily indicative of sepsis. A heart rate of 88/min is within normal limits (60-100/min). This client's signs do not strongly suggest sepsis.
Choice B: A heart rate of 132/min and a respiratory rate of 30/min are both elevated, which can be signs of sepsis. Sepsis can cause an increase in heart rate (tachycardia) and respiratory rate (tachypnea) as the body attempts to maintain adequate blood flow and oxygenation during a systemic infection.
Choice C: A decrease in the level of consciousness combined with a heart rate greater than 130/min could indicate sepsis, as confusion or changes in mental status are common symptoms when the body is fighting a severe infection.
Choice D: Bradypnea, or abnormally slow breathing, is not typically associated with sepsis, which more commonly causes rapid breathing. A WBC count of 10,000/mm^3 is at the upper limit of the normal range and does not necessarily indicate sepsis without other symptoms.
Choice E: A temperature of 36°C (96.8°F) is on the lower end of the normal body temperature range and does not suggest fever, which is a common sign of sepsis. A respiratory rate of 16/min is within the normal range (12-20/min) and does not indicate sepsis.
Question 3 of 5
A charge nurse is teaching a group of healthcare workers about hand hygiene to prevent infection. Which of the following information should the charge nurse include in the teaching?
Correct Answer: C
Rationale: Chlorhexidine is recommended for hand hygiene in immunocompromised patients due to its broad-spectrum antimicrobial activity. Artificial nails should be avoided, not just trimmed. Soap and water are required for C. difficile, as alcohol-based rubs are ineffective. Hand hygiene before eye drops should ensure clean hands, with no specific preference for alcohol-based rubs.
Question 4 of 5
A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?
Correct Answer: B
Rationale: Metabolic acidosis (pH 7.25, low HCO3- 19 mEq/L) is expected in CKD due to acid accumulation. Other options indicate alkalosis or respiratory issues not typical for CKD.
Question 5 of 5
A nurse in a provider's office is assessing a client who reports shoulder pain. Which of the following findings by the nurse indicates a rotator cuff injury?
Correct Answer: A
Rationale: The inability to abduct the arm at the shoulder is a classic sign of a rotator cuff injury. The rotator cuff is responsible for stabilizing the shoulder joint and aiding in various movements, including abduction. When there is a tear or significant weakness in the rotator cuff muscles, especially the supraspinatus muscle, the patient may be unable to lift the arm away from the body or may experience pain while doing so. A negative drop arm test would actually indicate that there is no rotator cuff injury. The drop arm test is performed by asking the patient to fully abduct the arm to 90 degrees and then slowly lower it. If the patient can control the motion and lower the arm smoothly, the test is negative. A positive drop arm test, where the patient cannot control the descent of the arm, would suggest a rotator cuff tear. While an alteration in the contour of the joint may indicate some form of shoulder pathology, it is not specific to a rotator cuff injury. Changes in the contour could be due to various conditions, including dislocation, arthritis, or other musculoskeletal disorders. A positive Tinel's sign is used to diagnose nerve compression or nerve damage, not rotator cuff injuries. It is performed by tapping over the course of a nerve to elicit a tingling sensation or pain in the distribution of the nerve. This sign is commonly associated with conditions like carpal tunnel syndrome.