ATI RN
ATI Advanced Med Surg Cohort 4 Exam Questions
Extract:
Medical History
Client reports falling and hitting their head and right shoulder after slipping on a wet floor yesterday. Denies loss of consciousness. Complains of pain in right shoulder. Has taken both acetaminophen and ibuprofen for pain with minimal relief obtained. Stayed up entire night playing video games yesterday to distract self from pain. Reports intermittent nausea and vomiting.
Vital Signs
• Oral temperature 37.5° C (99.6° F)
• Heart rate 76/min and regular
• Respiratory rate 20/min even and unlabored
• Blood pressure 112/70 mm Hg in left arm
• Pulse oximetry 98% on room air
Nurses' Notes
0900:
Reports pain in right shoulder. Limited range of motion noted. Rates pain as 7 on a scale of 0 to
Denies numbness and tingling in arm. No swelling or bruising over the shoulder. Fingers warm with capillary refill time less than 3 seconds, sensation intact. Drowsy. Oriented to person. place, and time. Irritable and restless at times. PERRLA. Glascow score of 15. No hematomas noted on head. No nausea or vomiting at this time.
1000:
Continues to report pain in right shoulder. Pain increased from 7 to 8 on a scale of 0 to 10. Increased drowsiness noted. Glascow unchanged.
Question 1 of 5
Complete the following sentence by using the list of options. The nurse should first address the client's........ followed by the client's........
Correct Answer: A,E
Rationale: Drowsiness may indicate neurological deterioration post-head injury, requiring priority assessment, followed by addressing shoulder pain to support recovery.
Extract:
Vital Signs
1230:
• Temperature 98.9˚F (37.2˚C)
• Heart Rate 70 /min
• Respiratory Rate 18 /min
• Blood Pressure 130/90 mm Hg
• Oxygen Saturation 99% on room air
• Pain score 0/10
1330:
• Temperature 99.9˚F (37.8˚C) Heart Rate 52 /min
• Respiratory Rate 32/min
• Blood Pressure 154/83mm Hg
• Oxygen Saturation 95% on room air
• Pain score 4/10
1430:
• Temperature 100.4˚F (38˚C)
• Heart Rate 40 /min
• Respiratory Rate 50/min
• Blood Pressure 190/40 mmHg
• Oxygen Saturation 97% on room air
• Pain score 9/10
Nurses' Notes
1230:
A nurse was called to the bedside and found the client on the floor. The client states: "I fell out of bed trying to get to the bathroom." They deny pain and are alert, and oriented to person, place, and time. Lungs clear to auscultation. Heart sounds S1, S2 heard. AROM of all extremities.
Glasgow coma scale 15. Provider notified. 1300:
Client states, "my head hurts." They are anxious and alert. Grimacing when moving their head. Glasgow coma scale 15. Provider notified.
1400:
Client experiencing Tonic-clonic seizure noted for approximately 1 minute. Airway maintained throughout. Client denies a history of seizures. Provider notified and at the bedside. Glasgow Coma Scale 14. Client is not oriented to time.
1430:
The client states "I'm scared I'm going to die! My head really hurts." Client is agitated and restless. Lungs sounds are clear to auscultation; however, their heart rate is irregular. Client is bradycardic. The client is experiencing weakness on the right side of their body. Their right eye pupil is dilated, and their left eye pupil is reactive to light. Oriented to person and place. Glasgow coma scale 13. They are confused and unable to follow commands.
Question 2 of 5
Complete the following sentence by using the lists of options. The client is at highest risk for developing...... as evidenced by the client's.......
Correct Answer: B,D
Rationale: Bradycardia and neurological symptoms post-fall suggest intracranial hemorrhage, with heart rate indicating increased ICP.
Extract:
Question 3 of 5
An unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU) 15 minutes ago has an oxygen saturation of 89%. Which action should the nurse take first?
Correct Answer: A
Rationale: The most appropriate first action would be to increase the oxygen flowrate to improve the patient's oxygen saturation levels. This intervention directly addresses the hypoxemia and can help prevent further complications related to low oxygen levels in the blood.
Question 4 of 5
A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status?
Correct Answer: C
Rationale: Asking the client to wiggle their toes assesses motor function and nerve integrity. In a neurovascular assessment, intact nerve function is crucial, as impaired nerve function can manifest as weakness or paralysis.
Question 5 of 5
The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon?
Correct Answer: C
Rationale: Excessive sanguineous fluid in the drain could indicate active bleeding or a hematoma formation, which are significant concerns after surgery. It should be reported to allow for appropriate intervention to prevent shock.