ATI RN
ATI Nur258 Med Surg 2 Final Exam Questions
Extract:
Medical History
Client admitted with report of polyuria and polydipsia.
Notable muscle twitching of upper extremities.
Past medical history: Varicella as a child. No other health issues.
Current medications: Occasional ibuprofen for pain.
Family history: Father had history of nephrogenic diabetes insipidus.
Physical Examination
Alert and oriented to person, place, and time.
Client states that they have had difficulty concentrating lately and are irritable.
Client reports occasional dizziness.
Skin is warm, dry, and scaly.
Mucous membranes dry and pink.
Lungs clear to auscultation bilaterally.
Abdomen soft, nondistended with active bowel sounds x 4.
Denies nausea, vomiting, or diarrhea.
Peripheral pulses 1+
Twitching noted in upper extremities, client states they have had twitching "for some time."
Nurses' Notes
0845:
Needed assistance to the bathroom, reports dizziness.
Urine output 1,500 mL.
Assisted client to bed.
Vitals taken.
Vital Signs
0800:
Temperature 37.4° C (99.4° F)
Heart rate 100/min
Respiratory rate 22/min
Blood pressure 108/78 mm Hg
SpO2 98% on room air
0900:
Temperature 37.4° C (99.4° F)
Heart rate 104/min
Respiratory rate 22/min
Blood pressure 96/70 mm Hg
Diagnostic Results
Basic metabolic profile
Sodium 157 mEq/L (nl. 136-145 mEq/L)
Potassium 3.49 mEq/L (nl. 3.5-5 mEq/L)
Chloride 102 mEq/L (nl. 98-106 mEq/L)
Magnesium 1.8 mEq/L (nl. 1.8-2.6 mEq/L)
Total calcium 9.7 mg/dL (nl. 8.8-10.4 mg/dL)
Complete blood count (CBC) with differential
Total white blood cell (WBC) count 6,500/mm3 (nl. 5,000-10,000/mm3)
Neutrophils 60% (55% to 70%)
Lymphocytes 30% (20% to 40%)
Monocytes 5% (2% to 8%)
Eosinophils 2.5% (1% to 4%)
Basophils 0.7% (0.5% to 1%)
Hemoglobin 21 g/dL (Male: 14 to 18 g/dL; Female: 12 to 16 g/dL)
Hematocrit 55% (Male: 42% to 52%; Female: 37% to 47%)
RBCs 5.7 x 106µL (Male: 4.7 to 6.1 x 106µL; Female: 4.2 to 5.4 x 106µL
Question 1 of 5
Complete the following sentence by using the lists of options. The nurse should first address the client's..... followed by the client's.....
Correct Answer: A,B
Rationale: Elevated sodium level (157 mEq/L) indicates hypernatremia, requiring urgent correction. Blood pressure should be addressed next to ensure stability.
Extract:
Question 2 of 5
A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?
Correct Answer: B
Rationale: The depth of the burn is crucial for assessing the severity of the injury as it directly impacts the treatment required and the potential for complications. Depth determines whether the burn is superficial, partial-thickness, or full-thickness.
Question 3 of 5
The nurse is caring for a client who is having chest pain. The healthcare provider prescribes an infusion of nitroglycerin. The initial dose is 12 mcg/min. The nitroglycerin is dispensed at a concentration of 100 mg/ 250 mL. How many mL/hr will the nurse set the infusion pump? (Round rate to the nearest tenth. Only enter numbers and decimals. Do not enter any letters in your answer.)
Correct Answer: 1.8
Rationale: Infusion rate = 0.72 mg/hr / 0.4 mg/mL = 1.8 mL/hr
Question 4 of 5
A nurse is planning care for a client who has leukemia and a platelet count of 60,000/mm³ (nl. 140,000-400,000/mm³). Which intervention should the nurse include in the plan of care?
Correct Answer: B
Rationale: Administering stool softeners is a key intervention for clients with thrombocytopenia, as it helps to prevent straining during bowel movements, which could cause rectal bleeding due to fragile blood vessels.
Extract:
Nurses Notes
Day 1:
Client is admitted with a 2-day history of headache, muscle aches, fever, sore throat, and fatigue.
Vital Signs
1200:
Temperature: 39.5°C (103.1°F)
Blood pressure: 128/56 mm Hg
Heart rate: 112/min
Respiratory rate: 22/min
SpO2: 96% on room air
1300:
Temperature: 39.9°C (103.8°F)
Blood pressure: 128/56 mm Hg
Heart rate: 112/min
Respiratory rate: 22/min
SpO2: 96% on room air
Diagnostic Results
1200:
Temperature: 39.5°C (103.1°F)
Blood pressure: 128/56 mm Hg
Heart rate: 112/min
Respiratory rate: 22/min
SpO2: 96% on room air
1300:
Temperature: 39.9°C (103.8°F)
Blood pressure: 128/56 mm Hg
Heart rate: 112/min
Respiratory rate: 22/min
SpO2: 96% on room air
Question 5 of 5
Which of the following actions should the nurse take? (Select all that apply.)
Correct Answer: A,B,D
Rationale: Encouraging fluid intake prevents dehydration. Wearing a mask prevents influenza spread. A private room reduces transmission risk.