ATI RN
ATI SP 250 Exam 3 Med Surg Exam Questions
Extract:
Nurses' Notes
Day 1:
0900:
Client admitted from emergency department with hemoptysis, dull chest pain, increasing fatigue, anorexia, nausea, chest tightness, and 3.2 kg (7 Ib) weight loss in 2 weeks. Heart rate regular, lung sounds with crackles in bilateral upper lobes. No edema. Airborne precautions initiated upon admission.
Day 2:
Client reports shortness of breath, nausea, and fatigue. Crackles auscultated bilaterally throughout lung fields. Productive cough, with thick, blood-streaked sputum. Bowel sounds active, no edema.
Question 1 of 5
A nurse on a medical-surgical unit is caring for a newly admitted client with a diagnosis of R/O tuberculosis. Which of the following findings should the nurse report to the provider?
Correct Answer: A
Rationale: This is because tuberculosis can affect the liver and cause hepatotoxicity, especially if the client is taking anti-tuberculosis medications. The nurse should monitor the client's liver function tests, such as AST and ALT levels, and observe for signs of liver damage, such as yellow sclera, dark urine, clay-colored stools, and abdominal pain.
Extract:
Question 2 of 5
A nurse is caring for a client who is receiving mechanical ventilation and has an ideal weight of 60 kg. The nurse should expect the tidal volume to be set at which of the following?
Correct Answer: B
Rationale: This is because the recommended tidal volume for mechanical ventilation is 6 to 8 mL/kg of ideal body weight.
Therefore, for a client who has an ideal weight of 60 kg, the tidal volume should be between 360 and 480 mL.
Question 3 of 5
A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?
Correct Answer: A
Rationale: This is because pursed-lip breathing helps to prevent air trapping and promote gas exchange by creating positive pressure in the airways. The nurse should also teach the client to exhale slowly and completely through pursed lips. The other interventions are not appropriate for a client who has COPD.
Question 4 of 5
A nurse is teaching a client who has emphysema about self-management strategies. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: C
Rationale: Clients with emphysema often have an increased caloric demand due to the effort required to breathe. A diet high in calories and protein can help maintain energy levels and prevent muscle wasting.
Question 5 of 5
A nurse is caring for a client who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications?
Correct Answer: A,C,D
Rationale: These interventions can help prevent complications such as stress ulcers, ventilator-associated pneumonia, and aspiration. Pantoprazole reduces gastric acid secretion and protects the mucosa from erosion. Verifying the ventilator settings ensures that the client is receiving adequate oxygenation and ventilation according to their needs and goals. Elevating the head of the bed reduces the risk of aspiration and improves lung expansion.