ATI RN
ATI Nur258 Med Surg 2 Final Exam Questions
Extract:
Nurses notes
Day 1:
Place the client on
Client reports fatigue, weight loss, and anorexia. Chemotherapy started as prescribed.
droplet precautions.
4 weeks later:
Client reports sore mouth and increased fatigue. Multiple bruises noted on elbows and legs.
Voided 350 mL of clear yellow urine.
Diagnostic results
Day 1:
Hematocrit (Hct) 38% (nl. 36-48%)
Hemoglobin (Hgb) 13 g/dL (nl. 12-16 g/dL)
Platelet 180,000/mm3 (nl. 150,000-400,000/mm3)
Total white blood cell (WBC) count 7000/mm3 (nl. 5,000-10,000/mm3)
4 weeks later:
Hct 35% (nl. 36-48%)
Hgb 11 g/dL (nl. 12-16 g/dL)
Platelet 100,000/mm3 (nl. 150,000-400,000/mm3)
Total WBC count 3000/mm3 (nl. 5,000-10,000/mm3)
with 0.9% sodium chloride every 4 hrs.
Question 1 of 5
For each potential healthcare provider's prescription at 4 weeks, click to specify if the prescription is anticipated, nonessential, or contraindicated for the client.
Correct Answer: A,C,E
Rationale: Placing the client on droplet precautions is anticipated to prevent infection in immunocompromised patients. A private room is anticipated to reduce infection risk. Rinsing the client's mouth with 0.9% sodium chloride is anticipated to manage sore mouth and maintain oral hygiene.
Extract:
Question 2 of 5
A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Clean gloves are appropriate for contact with the client or the wound, as MRSA is transmitted through direct contact. This prevents contamination while assessing the client.
Question 3 of 5
A nurse in the emergency department (ED) is triaging four clients following a mass casualty event. The nurse should identify which of the following clients as emergent?
Correct Answer: D
Rationale: Expiratory stridor indicates upper airway obstruction or severe respiratory distress, which is a life-threatening condition requiring immediate intervention. Stridor suggests possible airway compromise, which needs to be addressed urgently to prevent respiratory failure.
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 4 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 5 of 5
A nurse is teaching a female client with systemic lupus erythematosus (SLE) about exacerbating factors for their disease. Which statement about exacerbating factors by the client requires further teaching?
Correct Answer: A
Rationale: The statement about keeping the temperature cold to avoid becoming overheated requires further teaching. While avoiding excessive heat is important for individuals with SLE, maintaining an overly cold environment can also trigger symptoms, as cold temperatures can lead to vasoconstriction and Raynaud's phenomenon, which is common in SLE patients.