ATI RN
ATI Advanced Med Surg Final Exam 0924 Questions
Extract:
Medical History
Day 1:
Patient came from ER complaining of chest pain. CPR initiated in ER and return to ROSC after 3 minutes. Intubated in ER (ACVC FIO2 100% Mode; RR13; PEEP 3: Tidal Volume 300ml and transferred to ICU for further care.
Nurses' Notes
Day 1:
S/p intubation, patient was given rocuronium, fentanyl and versed per radiology. Patient currently sedated. Lung crackles and bronchi. Heart regular and moderate. Pulses +1 on all extremities with +2 pitting edema. Hypoactive bowel sounds.
Diagnostic Results
Day 1:
Chest x-ray shows bilateral basilar infiltration
CBC
WBC 7.8
HGB13
K+3.9
Creatinine 2.0
BUN 60
GFR 38
BNP 1800
Troponin 1.7
ABG (Before intubation): pH7.2 CO2 76 HCO3 18
Vital Signs
Day 1
IN ER before cardiac arrest: Temperature 37.6° C (99.7° F)
Blood pressure 174/86 mm Hg
Heart rate 98/min
Respiratory rate 27/min
Pulse oximetry 93% on room air
After Intubation:
Temp 100.0F
Blood Pressure 87/40
HR 125/min. Sinus Tachycardia
RR: 13
Pulse Ox 100%
Question 1 of 5
For each potential nursing action, click to specify if the action is essential, nonessential, or contraindicated for the client.
| Options | Essential | Nonessential | Contraindicated |
|---|---|---|---|
| Administer furosemide | |||
| Administer ordered Epinephrine drip | |||
| Administer ordered low dose dopamine | |||
| Insert an indwelling urinary catheter | |||
| Administer ordered nitroglycerin | |||
| Administed 0.9% NS 500ML bolus |
Correct Answer: A,B,C,D,F
Rationale: Furosemide, epinephrine, dopamine, urinary catheter, and NS bolus are essential for managing pulmonary edema, hypotension, and monitoring fluid balance. Nitroglycerin is nonessential unless indicated for ongoing angina.
Extract:
Question 2 of 5
A nurse is caring for a client who is postoperative following an open cholecystectomy. Which of the following actions should the nurse take when caring for the client's Jackson-Pratt (JP) drain?
Correct Answer: B
Rationale: Expelling the air from the JP bulb after emptying to re-establish suction is necessary to ensure that the drain continues to function correctly by maintaining negative pressure.
Question 3 of 5
A nurse is reviewing the laboratory values of a client who is at risk for disseminated intravascular coagulopathy (DIC). Which of the following values should the nurse report to the provider?
Correct Answer: B
Rationale: A fibrinogen level of 85 mg/dL is low. In DIC, fibrinogen levels decrease due to increased clotting and subsequent consumption of clotting factors.
Question 4 of 5
A nurse is reviewing the laboratory findings for a client who has idiopathic thrombocytopenic purpura (ITP). Which of the following findings should the nurse expect to be decreased?
Correct Answer: D
Rationale: Platelets are expected to be decreased in ITP, which is characterized by an immune-mediated destruction of platelets.
Question 5 of 5
A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate?
Correct Answer: B
Rationale: Performing a Romberg's test evaluates balance and proprioception, which is important for assessing the ability to ambulate safely in a person with ataxia.