ATI RN
ATI Advanced Med Surg Final Exam 0924 Questions
Extract:
Physical Examination
0800:
Alert and oriented to person and place
Skin pale and dry
Pupils equal, round, and reactive to light and accommodation Mucous
membranes moist and pink
Heart sounds regular and moderate
Peripheral pulses moderate
Capillary refill 3 seconds
Lungs sounds clear to auscultation bilaterally
Respirations labored at rest
Abdomen soft and nontender, active bowel sounds x 4 quadrants
No peripheral edema
Reports slight midsternal chest pain, rates pain as a 2 on a 0 to 10 pain scale
States they have been weak for the past 4 months with dizziness. Denies dizziness at this time.
1300
Returns to room after insertion of permanent pacemaker Alert and oriented to person, needs cues for time and place
Skin cool and dry
Heart sounds regular, heart rate 72/min
Lung sounds are coarse bilaterally
Hyperresonance noted upon percussion of chest wall
Respiratory rate 24/min and slightly labored
Oxygen saturation 2 U/min per nasal cannula 98%
Reports slight incisional pain left upper chest area
Small amount red drainage present on dressing over incisional site
Diagnostic Results
RBC count 5.2 million/mm3 (4.7 to 6.1 million/mm3) WBC count 7,000 mm (5,000 to 10,000 mm3)
Hemoglobin 15.4 g/dL (14 to 18 g/dL)
Hematocrit 48% (42% to 52%)
Platelets 250,000/mm3 (150,000 to 400,000/mm3)
Basic Metabolic Profile:
BUN 18 mg/dL (10 to 20 mg/dL)
Creatinine 1.0 mg/dL (0.6 to 1.3 mg/dL)
Total Calcium 9.5 mg/dL (9.0 to 10.5 mg/dL)
Carbon Dioxide 27 mEq/L (23 to 30 mEq/L) Chloride 101 mEq/L (98 to 106 mEq/L) Glucose 80 mg/dL (74 to 106 mg/dL) Potassium 5.1 mEq/L (3.5 to 5 mEq/L) Sodium 140 mEq/L (136 to 145 mEq/L)
Vital Signs
Temperature 36 Cm
Apical pulse 42min
Respiratory rate 25/min
Blood pressure 106/58 mm Hg
Oxygen saturation 54% on room air
Question 1 of 5
The nurse is caring for the client immediately following the insertion of the permanent pacemaker.Complete the following sentence by using the list of options. The nurse should monitor the client for __ and __ following permanent pacemaker placement.
Correct Answer: A,B
Rationale: Monitoring for incisional site bleeding ensures no complications like hematoma. Bradycardia monitoring ensures the pacemaker is functioning correctly.
Extract:
Question 2 of 5
A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the postoperative period?
Correct Answer: B
Rationale: Performing neurovascular checks of the extremities is the most important action to detect complications such as compartment syndrome or impaired circulation.
Question 3 of 5
A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?
Correct Answer: B
Rationale: Establishing the ability to communicate effectively is crucial for a left hemispheric CVA, which often affects language and speech functions.
Question 4 of 5
A nurse is planning postoperative care for a client who is scheduled for an ileal conduit procedure. The nurse should include which of the following in the client's plan of care? (Select all that apply.)
Correct Answer: A,C,D
Rationale: Hematuria is expected following an ileal conduit procedure. Monitoring hourly urine output ensures patency of the urinary system. Applying a skin barrier around the stoma site prevents skin breakdown.
Question 5 of 5
A nurse is teaching a client who is receiving treatment for metastatic colorectal cancer about the adverse effects of bevacizumab. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication?
Correct Answer: A
Rationale: Nosebleeds (epistaxis) are a common adverse effect of bevacizumab, as it can cause bleeding due to its anti-angiogenic properties.