ATI RN
ATI Advanced Med Surg Exam 3 Questions
Extract:
Nurse's Notes
Client came to the ER for increase SOB worsening dyspnea and restlessness. Respiratory rate is currently 32/min with shallow breath BP 198/78 mm Hg. Oxygen has been increased from 2 L nasal cannula to 50% face mask with little improvement of oxygen saturation. Current oxygen saturation is 91% on 50% facemask. Arterial blood gases drawn and sent to lab.
Diagnostic Results
ABGS:
pH 7.25 (7.35 to 7.45)
pCO2 62 mm Hg (35 to 45 mm Hg)
HCO3-22 mEq/L (22 to 26 mEq/L)
Question 1 of 5
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Correct Answer:
Rationale:
Extract:
Question 2 of 5
A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?
Correct Answer: B
Rationale: Muffled heart sounds, part of Beck's triad, indicate fluid accumulation in the pericardial sac, supporting cardiac tamponade.
Question 3 of 5
Which is(are) potential result(s) of end-organ damage from chronic hypertension? (Select all that apply.)
Correct Answer: A,B,C,E
Rationale: Chronic hypertension damages the heart, kidneys, brain, and predisposes to atrial fibrillation, leading to cardiac disease, renal insufficiency, stroke, and arrhythmias.
Extract:
Medical History
Client was brought to the ED by their family member due to mental status changes. The family member reports that they visit the client every other day and today the client did not initially realize who they were until several minutes after talking with them. The client has diabetes mellitus and takes insulin daily. A wound is noted on the right foot.
Nurses' Notes
Family member reports that the client did not initially realize who they were when they went to visit. Client is currently somnolent but rouses to verbal stimuli and is oriented to person. Glascow coma score is 13 and Modified Early Warning System (MEWS) score is 6. Respirations are even. unlabored and deep, with few crackles noted in lung bases bilaterally with auscultation. Mucous members are dry and pink. Abdomen soft with hypoactive bowel sounds. Radial and pedal pulses are palpable, no edema noted.
Skin is warm and dry. The right foot has a 2.5 cm x 3.3 cm (1 in x 1.3 in) superficial wound to the ball of the foot. The wound is moist with a scant amount of purulent drainage. Client stated they stepped on something last week while walking but did not notice a wound had occurred.
Client's family member reports that the client takes 10 units of regular insulin subcutaneously every morning and 5 units every evening with last dose taken this am. Also states that the client took two aspirin yesterday for a headache.
Vital Signs
Temperature 38.5°C (101.3° F) Pulse 110/min
Blood pressure 98/60 mm Hg Respiratory rate 26/min
Oxygen saturation 93% on 2 L nasal cannula
Diagnostic Results
RBC count 5.0 (Male 4.7 to 6.1)
WBC count 9,500 mm3 (5,000 to 10,000/mm3) Platelets 97,000/mm3 (150,000 to 400,000/mm3) Hemoglobin 15 g/dL (Male 14 to 18 g/dL)
Hematocrit 45% (Male 42% to 52%; Female 37% to 47%) Glucose 186 mg/dL (74 to 106 g/dL)
Question 4 of 5
It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications?
Correct Answer: C,D,E,F
Rationale: Administering antibiotics targets the infection, measuring lactate assesses tissue perfusion, fluid resuscitation restores volume, and blood cultures identify the causative organism, all critical within the first hour of sepsis management.
Extract:
Question 5 of 5
A patient with respiratory failure has a respiratory rate of 26 breaths/min and an oxygen saturation (SpO2) of 80%. The patient is increasingly pale and restless but follows commands. Which intervention will the nurse anticipate?
Correct Answer: B
Rationale: Severe hypoxemia and respiratory distress require endotracheal intubation for adequate ventilation and oxygenation.