ATI RN
ATI n200 Med Surg Exam Questions
Extract:
Question 1 of 5
The nurse is assessing clients for their risk of developing Scleroderma. Which of these clients should the nurse consider at lowest risk?
Correct Answer: B
Rationale: Lupus is associated with a higher risk of autoimmune conditions, including Scleroderma. A male working as a teacher is less likely to have occupational or genetic predispositions for Scleroderma. Chemical exposure can increase the risk of developing Scleroderma. A family history of Scleroderma raises the genetic risk of developing the condition.
Question 2 of 5
A client has been treated for low back pain which radiates down the posterior right leg. The client now has a new onset of urinary and bowel incontinence and weakness in both lower extremities. What is the nurse's first action?
Correct Answer: D
Rationale: Obtaining a walker does not address the acute neurological symptoms. Applying a diaper addresses the incontinence but not the underlying cause. Inserting a Foley catheter manages urinary incontinence but delays necessary evaluation. Notifying the physician is critical as these symptoms suggest cauda equina syndrome, a surgical emergency.
Question 3 of 5
The nurse is aware that a common adverse effect of anesthetic agents experienced by the client is:
Correct Answer: C
Rationale: Malignant hyperthermia (
C) is a rare but serious anesthetic reaction. Tachycardia (
A) and decreased respirations (
B) are less severe, and hypokalemia (
D) is unrelated.
Question 4 of 5
The priority nursing intervention for a client who has a serum sodium level of 154 mEq/L would be:
Correct Answer: C
Rationale: Fluid restriction (
C) corrects hypernatremia. Cardiac monitoring (
A), breath sounds (
B), and safety precautions (
D) are secondary.
Question 5 of 5
A client is admitted at 0700 with severe dehydration. The doctor orders D5W to run at 150 ml/hr. The client is ordered an IVPB antibiotic every 4 hours, that will be administered in 50 ml of IV fluid over 1 hour. The antibiotic is scheduled to start at 0800. The client is permitted liquids and takes the following: 4 oz gelatin 10 oz apple juice 500 ml of water 16 oz of ice chips which is consumed by the end of the shift Urine output is as follows: At 0900: 100 mL 1100: 250 mL 1330: 290 mL 1445: 250 ml At 1200, the client had 300 mL of a diarrhea stool. Calculate the cumulative fluid balance for the 0700-1500 shift.
Correct Answer: 1270 mL
Rationale: Intake: IV Fluids: D5W: 150 ml/hr from 0700 to 1500 (8 hours) = 150 ml/hr * 8 hr = 1200 ml. Antibiotic: 50 ml every 4 hours, starting at 0800. So, it will be administered at 0800 and 1200 = 50 ml * 2 = 100 ml. Oral Intake: Gelatin: 4 oz = 4 * 30 ml = 120 ml. Apple Juice: 10 oz = 10 * 30 ml = 300 ml. Water: 500 ml. Ice Chips: 16 oz (since ice chips are half liquid) = 16 * 30 ml / 2 = 240 ml.
Total Intake: 1200 ml (D5W) + 100 ml (Antibiotic) + 120 ml (Gelatin) + 300 ml (Apple Juice) + 500 ml (Water) + 240 ml (Ice Chips) = 2460 ml. Output: Urine Output: 0900: 100 ml, 1100: 250 ml, 1330: 290 ml, 1445: 250 ml. Diarrhea Stool: 1200: 300 ml.
Total Output: 100 ml + 250 ml + 290 ml + 250 ml + 300 ml = 1190 ml. Cumulative Fluid Balance: Intake - Output: 2460 ml - 1190 ml = 1270 ml. So, the cumulative fluid balance for the 0700-1500 shift is +1270 ml.