ATI RN
ATI Nur258 Med Surg 2 Final Exam Questions
Extract:
Nurses' Notes
Family member brought client to the ED for pain in left arm that began last evening. Client has a history of sickle cell disease diagnosed at age 4 years. Client has prescription for oral morphine sulfate and took one dose last evening at 1800 and this morning at 0900. Client reports no relief from pain, reporting it as 9 on a scale of 0 to 10.
Physical Examination
Client appears in moderate distress, reporting throbbing and stabbing pain to the left arm and hand. Client has full range of motion to arm, wrist, and fingers but resists movement due to pain. Capillary refill is less than 2 seconds, skin warm and dry, no edema, no rashes, no lesions. Client has used oral morphine sulfate in the past to alleviate pain. Reports taking dose of morphine sulfate last night at 1800 with no relief. Took an additional dose of morphine sulfate at 0900 this morning and states, "I am in still in pain, the morphine didn't work." Heart rate regular with no murmur, lungs clear, abdomen soft and nontender.
Vital Signs
Blood pressure 114/68 mm Hg
Heart rate 98/min
Respiratory rate 18/min
Temperature 37.1° C (98.9° F)
SpO2 95% on room air
Question 1 of 5
For each potential healthcare provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.
| Options | Anticipated | Nonessential | Contraindicated |
|---|---|---|---|
| Intravenous fluid administration | |||
| Ice packs to affected area 15 min on/15 min off | |||
| Ambulation in hallway with supervision | |||
| Hydromorphone intravenously (IV) for pain | |||
| Acetaminophen orally (PO) for pain | |||
| Oxygen 2 L/min via nasal cannula |
Correct Answer: A,D
Rationale: Intravenous fluid administration is anticipated to reduce viscosity of sickled cells. Hydromorphone IV is anticipated for severe pain unresponsive to oral morphine.
Extract:
Question 2 of 5
A diabetes nurse educator is discussing 'sick day rules' with a client newly diagnosed with diabetes mellitus type 1. Which statement by the client indicates a need for further teaching?
Correct Answer: B
Rationale: It is crucial for clients with diabetes to continue taking insulin during illness, even if they are unable to eat. Insulin needs may increase due to stress or infection, and not taking insulin could lead to hyperglycemia or diabetic ketoacidosis. Checking blood sugar every 2 hours is correct, but insulin should not be omitted.
Question 3 of 5
A nurse is working with a limited staff because of a severe storm in the area. The facility incident commander has initiated disaster protocols. Which of the following actions should the nurse take first?
Correct Answer: B
Rationale: In a disaster situation, prioritizing care for clients with life-threatening emergencies is crucial to ensure that those in the most critical condition receive immediate attention. This aligns with triage principles and ensures that limited resources are used effectively.
Question 4 of 5
A nurse is caring for a client who is experiencing pooling of blood in the periphery. Which of the following occurs in a client with distributive shock?
Correct Answer: B
Rationale: Decreased venous return occurs in distributive shock due to the pooling of blood in the periphery, leading to reduced preload and decreased cardiac output.
Question 5 of 5
A nurse witnesses a motor vehicle crash and finds a client who is not breathing. The nurse suspects the client has a cervical vertebrae fracture. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The first priority in this situation is to open the client's airway using the jaw-thrust maneuver. This technique is preferred for clients with suspected spinal injuries to avoid further spinal cord damage. Ensuring the airway is open and providing oxygenation are immediate life-saving actions.