ATI RN
ATI Nur258 Med Surg 2 Final Exam Questions
Extract:
Question 1 of 5
The nurse is caring for a client who has disseminated intravascular coagulation (DIC). The healthcare provider prescribes an infusion of heparin. Based on the protocol, the initial dose is 14 units/kg/hr. The heparin is dispensed at a concentration of 25,000 units/250 ml. The client weighs 79.1 kg. How many mL/hr will the nurse set the Infusion pump? (Round the rate to nearest tenth. Only enter numbers and decimals. Do not enter any letters in your answer.)
Correct Answer: 11.1
Rationale: Infusion rate = 1107.4 units/hr / 100 units/mL = 11.074 mL/hr, rounded to 11.1 mL/hr.
Question 2 of 5
A nurse in the emergency department (ED) is triaging four clients following a mass casualty event. The nurse should identify which of the following clients as emergent?
Correct Answer: D
Rationale: Expiratory stridor indicates upper airway obstruction or severe respiratory distress, which is a life-threatening condition requiring immediate intervention. Stridor suggests possible airway compromise, which needs to be addressed urgently to prevent respiratory failure.
Question 3 of 5
A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?
Correct Answer: C
Rationale: Reducing protein intake is crucial for decreasing ammonia production. In clients with hepatic encephalopathy, proteins are broken down into ammonia, which the impaired liver cannot detoxify effectively, leading to worsened symptoms.
Therefore, reducing dietary protein can help lower ammonia levels.
Question 4 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.
Question 5 of 5
The critical care nurse is preparing to initiate an infusion of a vasopressor medication to a client in septic shock. What goal of this treatment should the nurse identify?
Correct Answer: D
Rationale: The primary goal of vasopressor therapy in septic shock is to maintain an adequate mean arterial pressure (MAP) to ensure adequate organ perfusion and prevent organ failure.