ATI RN
ATI Nur258 Med Surg 2 Final Exam Questions
Extract:
Nurses' Notes
0800:
Lungs clear to auscultation in all lobes anterior and posterior. Intravenous (IV) 0.9% sodium chloride infusing into left forearm at 125 mL/hr. Bowel sounds hypoactive in all four quadrants. Abdomen soft and tender to palpation. Abdominal dressing dry and intact. Scant vaginal bleeding observed. Intermittent pneumatic compression devices observed on bilateral lower extremities. Foley catheter intact and patent draining to bedside bag. Instructed client to turn and cough every 2 hrs. while awake. Demonstrated splinting incision with pillow when coughing
1000:
Attempted to assist client with turning and coughing.
Vital Signs
1000:
Temperature 37.3° C (99.14° F)
Blood pressure 116/76 mm Hg
Heart rate 90/min
Respiratory rate 20/min
SpO2 93% on room air
Question 1 of 5
Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing....,.........and....
Correct Answer: A,B,C
Rationale: Postoperative clients are at risk for pneumonia due to reduced lung expansion, DVT due to immobility, and pressure injuries from prolonged bed rest.
Extract:
Medical History
1600:
Client brought to facility by adult son who found the client on the floor of their living room "passed out from drinking." Client has 5.1-cm (2-in) laceration on forehead with dried blood present. The son states client "has been drinking my entire life. I don't know how they are still alive."
Plan:
Admit for alcohol use disorder, observe for alcohol withdrawal.
Vital Signs
1600
Admission:
Temperature 36.° C (97° F)
Blood pressure 98/66 mm Hg
Heart rate 76/min
Respiratory rate 16/min
Spo2 93% on room air
Diagnostic Results
1800:
Blood alcohol 360 mg/dL (nl. 0-50 mg/dL)
Complete blood count (CBC):
White blood cell (WBC) count 6,500/mm3 (nl. 5,000-10,000/mm3)
Red blood cell (RBC) count 4.0 million/mm3 (nl. 4.2 to 5.4 million/mm3)
Hemoglobin (Hgb) 11 g/dl (nl. 12-16 g/dL)
Hematocrit (Hct) 33% (nl. 36-48%)
Platelet count 350,000/mm3 (nl. 140,000-400,000/mm3)
Albumin 3.5 g/dL (nl. 3.5-5.2 g/dL)
Ammonia 79 mcg/dL (nl. 15-60 mcg/dL)
Question 2 of 5
Complete the following sentence by using the lists of options. The client is at highest risk for developing..... evidenced by the client's......
Correct Answer: A,B
Rationale: Encephalopathy is a complication of alcohol withdrawal, evidenced by elevated ammonia levels contributing to neurological symptoms.
Extract:
Question 3 of 5
A nurse is caring for a client who has a new diagnosis of Clostridium difficile and is placed on contact precautions. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Removing the protective gown before leaving the client's room is correct as it prevents the spread of C. difficile spores outside the isolation area.
Question 4 of 5
A nurse is providing education about levothyroxine to a client diagnosed with primary hypothyroidism. Which of the following statements should the nurse use when teaching the client?
Correct Answer: A
Rationale: Levothyroxine is used to replace thyroid hormone in hypothyroidism. Symptoms like tremors, nervousness, and insomnia can indicate that the dose is too high, suggesting possible hyperthyroidism.
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.