ATI RN
ATI Nur258 Med Surg 2 Final Exam Questions
Extract:
Nurses Notes
Day 3 of hospitalization:
0730
Fingerstick blood glucose, fasting 114 mg/dL (nl. 60 to 110 mg/dL)
NPH insulin 40 units subcutaneous administered into abdomen as prescribed
0830:
Client reports nausea with emesis; vomited morning meal
1130:
Client reports feeling shaky, hungry, skin cool and diaphoretic Fingerstick blood glucose 55 mg/dL (nl. 60 to 110 mg/dL)
Vital Signs
Day 3 of hospitalization:
0700:
Temperature 37.3 °C (99.1 °F)
Blood pressure 118/62 mm Hg
Heart rate 84/min
Respiratory rate 20/min
SpO2 97% on room air
1130:
Temperature 37.8 °C (100 °F)
Blood pressure 104/56 mm Hg
Heart rate 118/min
Respiratory rate 20/min
SpO2, 95% on room air
Diagnostic Results
Day 3 of hospitalization:
HbA1c: 8.01% (nl. 4.4-6,4% )
Question 1 of 5
Select the 3 findings that require immediate follow-up.
Correct Answer: A,B,D
Rationale: Hypoglycemia (glucose 55 mg/dL), shakiness, and elevated heart rate require immediate follow-up to manage low blood sugar and assess underlying causes.
Extract:
Question 2 of 5
A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?
Correct Answer: B
Rationale: The depth of the burn is the primary factor in assessing burn severity. It determines the level of tissue damage and guides treatment decisions. Depth classifications include superficial, partial-thickness, and full-thickness burns.
Extract:
Vital Signs
1000:
Temperature 38.1°C (100.6°F)
Heart rate 122/min
Respiratory rate 26/min
Blood pressure (BP) 136/85 mm Hg
SpO2 93% on room air
Physical Examination
1000:
Reports flu-like symptoms of headache, body aches, sore throat, low- grade fever, shortness of breath, productive cough.
Swollen lymph nodes.
Dry skin with rash.
Weight loss of 15 lbs. over last 3 months with report of diarrhea and anorexia, difficulty eating due to oral ulcers.
Diagnostic Results
1200:
Chest x-ray:
Areas of increased density and white infiltrates to lower right lobe indicative of pneumonia
1600:
Hemoglobin (Hgb) 11 g/dL (nl. 12-16 g/dL)
Hematocrit (Hct) 36% (nl. 36-48%)
Platelet count 155,000/mm3 (nl. 140,000-400,000/mm)
White blood cell (WBC) count 4,500/mm3 (nl. 5,000-10,000/mm)
CD4 count 400 cells/mm3.cpl 600 1 500 cells/mm3
Question 3 of 5
Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing...... and......
Correct Answer: A,B
Rationale: Low CD4 count and symptoms like fever and cough indicate sepsis risk. Weight loss and anorexia suggest malnutrition.
Extract:
Question 4 of 5
A nurse is caring for a client who experienced a right-hemispheric stroke and has extreme muscle weakness on the affected side. Which nursing intervention is most appropriate for this client?
Correct Answer: A
Rationale: A client with extreme muscle weakness on the affected side should use a cane or other assistive devices to aid in mobility and ensure safety. This intervention helps the client maintain stability and prevent falls.
Extract:
Nurses' Notes
0800:
Lungs clear to auscultation in all lobes anterior and posterior. Intravenous (IV) 0.9% sodium chloride infusing into left forearm at 125 mL/hr. Bowel sounds hypoactive in all four quadrants. Abdomen soft and tender to palpation. Abdominal dressing dry and intact. Scant vaginal bleeding observed. Intermittent pneumatic compression devices observed on bilateral lower extremities. Foley catheter intact and patent draining to bedside bag. Instructed client to turn and cough every 2 hrs. while awake. Demonstrated splinting incision with pillow when coughing
1000:
Attempted to assist client with turning and coughing.
Vital Signs
1000:
Temperature 37.3° C (99.14° F)
Blood pressure 116/76 mm Hg
Heart rate 90/min
Respiratory rate 20/min
SpO2 93% on room air
Question 5 of 5
Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing....,.........and....
Correct Answer: A,B,C
Rationale: Postoperative clients are at risk for pneumonia due to reduced lung expansion, DVT due to immobility, and pressure injuries from prolonged bed rest.