ATI RN
ATI RN Adult Medical Surgical 2023 III Questions
Extract:
Question 1 of 5
A nurse on a medical-surgical unit is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement?
Correct Answer: C
Rationale: A bed alarm alerts staff to wandering attempts, enhancing safety for a client with dementia.
Extract:
Patient Summary
Presenting Complaint:
Time of Arrival: 0900 hours
Symptoms: Client reports not feeling well for the past 12 hours, with increasing blood glucose levels. Client has a history of type 1 diabetes mellitus and hypertension. Recent treatment for bronchitis and pneumonia. Reports nausea, decreased appetite, frequent urination, and extreme thirst.
Medical History:
Conditions: Type 1 diabetes mellitus, hypertension.
Recent Illnesses: Bronchitis, pneumonia.
Nurses' Notes
0900 Hours:
Client presents with a history of type 1 diabetes mellitus and hypertension. The client is alert and oriented x4. Heart and lung sounds are clear. The client reports frequent urination, extreme thirst, nausea, and decreased appetite. Bowel sounds are hyperactive in all 4 quadrants. Bilateral pedal pulses are 1+. Slight tenting of skin noted. Peripheral IV established, and labs drawn.
Vital Signs
0900 Hours:
Temperature: 36.8°C (98.2°F)
Pulse Rate: 110/min
Respiratory Rate: 18/min
Blood Pressure: 96/65 mm Hg
Oxygen Saturation: 96% on room air
1400 Hours:
Temperature: 36.8°C (98.2°F)
Pulse Rate: 84/min
Respiratory Rate: 16/min
Blood Pressure: 106/76 mm Hg
Laboratory Results
0915 Hours:
Blood Glucose: 468 mg/dL (Normal: 74-106 mg/dL)
pH: 7.30 (Normal: 7.35-7.45)
Potassium: 5.5 mEq/L (Normal: 3.5-5.0 mEq/L)
Sodium: 138 mEq/L (Normal: 136-145 mEq/L)
Chloride: 101 mEq/L (Normal: 98-106 mEq/L)
BUN: 21 mg/dL (Normal: 10-20 mg/dL)
Creatinine: 1.7 mg/dL (Normal: 0.5-1.1 mg/dL)
Urine Dipstick: Positive for ketones (Normal: Negative)
Provider's Prescriptions
Fluids: Administer 0.9% sodium chloride at 15 ml/kg/hr for 1 hr, then reduce to 10 ml/kg/hr.
Potassium: Potassium chloride 20 mEq/L IV PRN if potassium is less than 5.0 mEq/L.
Insulin: Regular insulin continuous infusion, titrate per DKA protocol once potassium is greater than 3.3 mEq/L.
Anti-nausea: Ondansetron 4 mg IV bolus every 4 hr PRN for nausea.
Pain Relief: Acetaminophen 650 mg every 4 hr PRN for pain.
Magnesium: Magnesium sulfate 2 g IV over 2 hr for hypomagnesemia.
Monitoring: Strict intake and output, blood glucose level hourly.
Question 2 of 5
For each assessment finding, click to specify if the assessment finding is consistent with diabetic ketoacidosis (DKA) or hyperglycemic-hyperosmolar state (HHS).
| Options | DKA | HHS |
|---|---|---|
| Urine ketones | ||
| Creatinine greater than expected reference range | ||
| Blood glucose greater than expected reference range | ||
| Skin turgor | ||
| Blood pH greater than expected reference range |
Correct Answer: (See rationale)
Rationale: Urine ketones and low pH are specific to DKA; high glucose and poor skin turgor apply to both; high creatinine is more common in HHS.
Extract:
Question 3 of 5
A nurse is assessing a client following the administration of an initial dose of captopril. Which of the following findings indicates an anaphylactic response?
Correct Answer: B
Rationale: Laryngeal edema is a sign of anaphylaxis, a severe allergic reaction requiring immediate intervention.
Question 4 of 5
A nurse is caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings should the nurse identify as an indication that the medication was effective?
Correct Answer: D
Rationale: Morphine reduces anxiety and preload in heart failure, improving comfort and respiratory effort.
Question 5 of 5
A nurse is preparing to obtain a guaiac smear sample from a client for fecal occult blood testing. Which of the following actions should the nurse plan to take?
Correct Answer: C
Rationale: Urine can contaminate the sample, leading to inaccurate fecal occult blood test results.