ATI RN
ATI Advanced Med Surg Final Exam 0924 Questions
Extract:
Vital Signs:
1500:
Temperature 37.3° C (99.1° F)
BP 154/64 mm Hg
Heart rate 105/min
Respiratory rate 26/min
Oxygen saturation 93% on room air
Medical History
Cirrhosis
Hypertension, controlled with metoprolol therapy
Type 2 diabetes mellitus, controlled with glipizide therapy
Physical Examination
1500:
Client presents with decreased level of consciousness, slurred speech, and impaired concentration. Client is lethargic, does not respond to questions or simple commands. Pupils round, reactive to light and accommodation. Partner states client has been sleeping during the day and remains awake at night.
Skin is dry and jaundiced with petechiae present to arms and legs.
S1 S2 heard on auscultation. +1 pulses on bilateral radial and pedal pulses. Peripheral edema +3 present in bilateral lower extremities.
Crackles auscultated in bilateral lower lobes.
Abdomen distended with ascites. Hypoactive bowel sounds present in all four quadrants. Partner reports no knowledge of rectal bleeding, states client has been tolerating diet with no nausea or vomiting.
Client placed in semi-Fowler's position at 45°, feet elevated. Bed in low position. Partner remains at client's bedside.
Diagnostic Results
1700:
Albumin 2.9 g/dL (3.5 to 5 g/dL)
Ammonia 250 mcg/dL (10 to 80 mcg/dL)
Sodium 138 mEq/L (136 to 145 mEq/L)
Potassium 4.8 mEq/L (3.5 to 5 mEq/L)
Fasting glucose 148 mg/dL (70 to 110 mg/dL)
BUN 18 mg/dL (10 to 20 mg/dL)
Creatinine 0.8 mg/dL (0.5 to 1 mg/dL)
Question 1 of 5
The client is exhibiting manifestations of __ due to the client's __
Correct Answer: A
Rationale: The client is experiencing alterations in their level of consciousness and has an elevated ammonia level, indicative of encephalopathy due to liver failure from cirrhosis.
Extract:
Medical History
75-year-old male who reports increased dyspnea x 4 days. Denies cough or fever.
Past medical history: Two pack a day smoker for 50 years. Diagnosed with lung cancer 4 years ago and treated. Over the last year has developed frequent pleural effusions treated with thoracentesis. Hypertension.
Surgical history: Right lower lobectomy 4 years ago. Left hernia repair 25 years ago.
Nurses' Notes:
1000:
Alert and oriented x3. Reports difficulty breathing.
Respirations 28/min and labored.
Oxygen saturation 91%
Crackles auscultated left lung base. Fremitus decreased left chest wall.
1200:
Thoracentesis performed by provider.
1,000 mL cloudy yellow fluid removed, labeled and sent to lab for testing.
Dressing applied to puncture site.
Respiratory rate 24/min and regular. Oxygen saturation 95%
Question 2 of 5
The nurse is caring for the client following a thoracentesis. (Select the 3 findings that require immediate follow-up.)
Correct Answer: A,B,D
Rationale: Decreased lung sounds, heart rate 110/min, and subcutaneous emphysema indicate potential complications like pneumothorax or procedure-related issues requiring immediate follow-up.
Extract:
Question 3 of 5
A nurse is providing discharge teaching to a client who has an implantable cardioverter/defibrillator (ICD). Which of the following information should the nurse include?
Correct Answer: B
Rationale: The client should hold his cell phone on the side opposite the ICD to avoid interference with the ICD's functioning.
Question 4 of 5
A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions?
Correct Answer: B
Rationale: Defibrillation is used for pulseless ventricular tachycardia or ventricular fibrillation to restore a normal heart rhythm.
Question 5 of 5
A nurse is teaching a client who has rheumatoid arthritis about self-care strategies for managing the disease. Which of the following activities should the nurse include in the teaching?
Correct Answer: B
Rationale: Pressing water from a sponge rather than wringing it is a good strategy to avoid straining the joints.