ATI RN
ATI RN Adult Medical Surgical 2023 III Questions
Extract:
Patient Summary
Presenting Complaint:
Time of Arrival: 0900 hours
Symptoms: Client reports not feeling well for the past 12 hours, with increasing blood glucose levels. Client has a history of type 1 diabetes mellitus and hypertension. Recent treatment for bronchitis and pneumonia. Reports nausea, decreased appetite, frequent urination, and extreme thirst.
Medical History:
Conditions: Type 1 diabetes mellitus, hypertension.
Recent Illnesses: Bronchitis, pneumonia.
Nurses' Notes
0900 Hours:
Client presents with a history of type 1 diabetes mellitus and hypertension. The client is alert and oriented x4. Heart and lung sounds are clear. The client reports frequent urination, extreme thirst, nausea, and decreased appetite. Bowel sounds are hyperactive in all 4 quadrants. Bilateral pedal pulses are 1+. Slight tenting of skin noted. Peripheral IV established, and labs drawn.
Vital Signs
0900 Hours:
Temperature: 36.8°C (98.2°F)
Pulse Rate: 110/min
Respiratory Rate: 18/min
Blood Pressure: 96/65 mm Hg
Oxygen Saturation: 96% on room air
1400 Hours:
Temperature: 36.8°C (98.2°F)
Pulse Rate: 84/min
Respiratory Rate: 16/min
Blood Pressure: 106/76 mm Hg
Laboratory Results
0915 Hours:
Blood Glucose: 468 mg/dL (Normal: 74-106 mg/dL)
pH: 7.30 (Normal: 7.35-7.45)
Potassium: 5.5 mEq/L (Normal: 3.5-5.0 mEq/L)
Sodium: 138 mEq/L (Normal: 136-145 mEq/L)
Chloride: 101 mEq/L (Normal: 98-106 mEq/L)
BUN: 21 mg/dL (Normal: 10-20 mg/dL)
Creatinine: 1.7 mg/dL (Normal: 0.5-1.1 mg/dL)
Urine Dipstick: Positive for ketones (Normal: Negative)
Provider's Prescriptions
Fluids: Administer 0.9% sodium chloride at 15 ml/kg/hr for 1 hr, then reduce to 10 ml/kg/hr.
Potassium: Potassium chloride 20 mEq/L IV PRN if potassium is less than 5.0 mEq/L.
Insulin: Regular insulin continuous infusion, titrate per DKA protocol once potassium is greater than 3.3 mEq/L.
Anti-nausea: Ondansetron 4 mg IV bolus every 4 hr PRN for nausea.
Pain Relief: Acetaminophen 650 mg every 4 hr PRN for pain.
Magnesium: Magnesium sulfate 2 g IV over 2 hr for hypomagnesemia.
Monitoring: Strict intake and output, blood glucose level hourly.
Question 1 of 5
For each assessment finding, click to specify if the assessment finding is consistent with diabetic ketoacidosis (DKA) or hyperglycemic-hyperosmolar state (HHS).
| Options | DKA | HHS |
|---|---|---|
| Urine ketones | ||
| Creatinine greater than expected reference range | ||
| Blood glucose greater than expected reference range | ||
| Skin turgor | ||
| Blood pH greater than expected reference range |
Correct Answer: (See rationale)
Rationale: Urine ketones and low pH are specific to DKA; high glucose and poor skin turgor apply to both; high creatinine is more common in HHS.
Extract:
Question 2 of 5
A nurse is planning care for a client who has a seizure disorder. Which of the following equipment should the nurse place in the client's room?
Correct Answer: D
Rationale: An oral airway can be used during a seizure to maintain airway patency if needed, ensuring safety.
Question 3 of 5
A nurse in the emergency department is evaluating a young adult client for bacterial meningitis. Which of the following actions should the nurse take as part of the focused assessment?
Correct Answer: A
Rationale: Nuchal rigidity is a hallmark sign of bacterial meningitis, assessed by checking neck stiffness.
Question 4 of 5
A nurse is caring for a client who has a spinal cord injury and has developed autonomic dysreflexia. Identify the sequence of steps the nurse should take.
Correct Answer: D,B,A,C
Rationale: Positioning upright reduces blood pressure, emptying the bladder removes the trigger, antihypertensives manage severe hypertension, and documenting ensures future care planning.
Question 5 of 5
A nurse suspects that a client who has diabetes mellitus is experiencing hypoglycemia. Which of the following assessment findings supports this suspicion?
Correct Answer: C
Rationale: Cool, clammy skin is a classic sign of hypoglycemia due to the body's stress response and sweating.