ATI RN
ATI Advanced Med Surg Exam 4 Questions
Extract:
Question 1 of 5
During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next?
Correct Answer: C
Rationale: Further assessment for the cause of decreased circulation is critical to prevent limb loss.
Question 2 of 5
An unresponsive 79-yr-old patient is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 105.4° F (40.8° C), blood pressure (BP) is 88/50 mm Hg, and pulse is 112 beats/min. What action should the nurse plan to take?
Correct Answer: C
Rationale: Applying wet sheets and a fan rapidly lowers core temperature to prevent organ damage.
Question 3 of 5
A nurse is preparing to administer 0.9% sodium chloride (NSS) 3000 mL IV to infuse over 24 hr. The drop factor on the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 21
Rationale: 3000 mL over 24 hr (1440 min) with 10 gtt/mL drop factor: 3000 ÷ 1440 × 10 = 20.8, rounded to 21 gtt/min.
Extract:
Nurses Notes
1730: Report received from PACU:
Indwelling urinary catheter draining 850 mL dark red urine with clots, taped to left thigh, taut, no kinks. Continuous bladder irrigation with sterile water running.
22 g peripheral IV to left forearm: lactated Ringer's 125 mL/hr continuous infusion via pump.
Surgical incision to suprapubic area covered with gauze dressing with minimal amount of sanguineous drainage.
Post Op Day 1
0800:
Indwelling urinary catheter draining pink urine with small clots, attached to securement device on thigh, drainage bag attached to bed Catheter tube without kinks and patent, 150 mL in last 8hr.
Pain level 7 on 0 to 10 scale. Receiving morphine via PCA per pain management.
Scrotal and penile is edematous along with decreased urinary output Ecchymosis to skin surrounding surgical incision, moderate amount of serous drainage, cleansed with wound cleanser, patted dry, covered with 4X4 gauze dressing
Reports feeling bloated. Bowel sounds hypoactive. Last bowel movement day before surgery.
Vital Signs
Post Op Day 0
1730
Temperature: 37.3°C (99.2°F) oral
Heart rate: 72/min
Respiratory rate: 16/min.
Blood pressure: 116/68 mm Hg
Sa02: 98 % on room air
Post Op Day 1
0800
Temperature: 36.7°C (98.1°F) oral
Heart rate: 84/min
Respiratory rate: 20/min
Blood pressure: 148/76 mm Hg
Sa02-98% on room air
Question 4 of 5
A nurse is caring for a client who has had an open radical prostatectomy. For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.
| Options | Anticipated | Nonessential | Contraindicated |
|---|---|---|---|
| Administer a docusate sodium suppository. | |||
| Apply ice to the scrotum and penis. | |||
| Administer an antispasmodic medication. | |||
| Place the client in the sitting position while in bed. | |||
| Teach the client how to use a leg bag. |
Correct Answer: A,B,C,E
Rationale: A: Docusate sodium prevents constipation, common post-surgery. B: Ice reduces scrotal/penile edema. C: Antispasmodics manage catheter-related spasms. D: Sitting may not be necessary and could cause discomfort. E: Leg bag education is essential for catheter management.
Extract:
Question 5 of 5
A nurse is teaching a group of clients about tick-borne illnesses. Which of the following information should the nurse include in the teaching regarding ticks?
Correct Answer: C
Rationale: Grasping the tick close to the skin with tweezers minimizes infection risk.