ATI RN
ATI Nur258 Med Surg 2 Final Exam Questions
Extract:
Vital Signs
1000:
Temperature 38.1°C (100.6°F)
Heart rate 122/min
Respiratory rate 26/min
Blood pressure (BP) 136/85 mm Hg
SpO2 93% on room air
Physical Examination
1000:
Reports flu-like symptoms of headache, body aches, sore throat, low- grade fever, shortness of breath, productive cough.
Swollen lymph nodes.
Dry skin with rash.
Weight loss of 15 lbs. over last 3 months with report of diarrhea and anorexia, difficulty eating due to oral ulcers.
Diagnostic Results
1200:
Chest x-ray:
Areas of increased density and white infiltrates to lower right lobe indicative of pneumonia
1600:
Hemoglobin (Hgb) 11 g/dL (nl. 12-16 g/dL)
Hematocrit (Hct) 36% (nl. 36-48%)
Platelet count 155,000/mm3 (nl. 140,000-400,000/mm)
White blood cell (WBC) count 4,500/mm3 (nl. 5,000-10,000/mm)
CD4 count 400 cells/mm3.cpl 600 1 500 cells/mm3
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
Rationale: Low CD4 count and symptoms like fever and cough indicate sepsis risk. Weight loss and anorexia suggest malnutrition.
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 2 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.
Extract:
Question 3 of 5
A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?
Correct Answer: C
Rationale: Reducing protein intake is crucial for decreasing ammonia production. In clients with hepatic encephalopathy, proteins are broken down into ammonia, which the impaired liver cannot detoxify effectively, leading to worsened symptoms.
Therefore, reducing dietary protein can help lower ammonia levels.
Question 4 of 5
A client on the oncology unit is receiving a chemotherapy agent, and the nurse is aware that a significant side effect of this medication is thrombocytopenia. For which symptom should the nurse assess in clients at risk for thrombocytopenia?
Correct Answer: A
Rationale: Petechiae are small, red or purple spots on the skin that indicate bleeding under the skin and are a classic sign of thrombocytopenia, a condition characterized by a low platelet count.
Question 5 of 5
A client with chronic pain is using aspirin regularly to control her pain symptoms. She presents to the hospital with abdominal pain, pale skin, afebrile, and a blood pressure (BP) of 83/45 mm Hg. Which type of shock is the client most likely experiencing?
Correct Answer: A
Rationale: Hypovolemic shock is characterized by low blood pressure, pale skin, and abdominal pain due to significant fluid loss or hemorrhage. The client's symptoms, including hypotension and abdominal pain, suggest a reduction in blood volume potentially caused by gastrointestinal bleeding or ulceration, which is consistent with chronic aspirin use.