ATI RN
ATI Nur 112 Med Surg Exam Questions
Extract:
History and Physical
Vital Signs
Nurses' notes
Laboratory results
Flow sheet
Orders
The client is a 75-year-old female admitted to the preoperative area to prepare for pacemaker insertion. The client reports she is having this done because her heart rate has been staying very low, she is always tired, and she has passed out once from a low heart rate. The client has a history of worsening symptomatic bradycardia and a history of atrial fibrillation controlled by medication. She has been off anticoagulants for 4 days to prepare for the procedure.
Question 1 of 5
The nurse is preparing the client's plan of care. Select 4 findings that would indicate to the nurse that the administration of the vancomycin antibiotic would be safe to administer.
| No known allergies |
| Dosage in safe range |
| Potassium 4.4 mEq/L (4.4 mmol/L) |
| Peripheral IV in large vein |
| Used for prophylaxis |
| Blood urea nitrogen 17 mg/dl (6.07 mmol/L) |
Correct Answer: A,B,D,E
Rationale: No allergies, safe dosage, appropriate IV site, and prophylactic use ensure safe vancomycin administration.
Extract:
History and Physical
Nurses Notes
The client is a 75-year-old female admitted to the preoperative area to prepare for pacemaker insertion. Client reports she is having this done because her heart rate has been staying very low. She is always tired, and she has passed out once from a low heart rate. Client has a history of worsening symptomatic bradycardia. History of atrial fibrillation controlled by medication. Has been off anticoagulants for 4 days to prepare for the procedure.
Question 2 of 5
The nurse is evaluating the client's progress and nursing implementations. Bold the words to highlight the findings that would indicate the client has recovered from the adverse drug reaction.
| Shaking is lessened. |
| Client is no longer flushed. |
| No longer itching. |
| Anxiety has decreased. |
| Skin warm and dry. |
| Heart rate 62 beats/minute |
| Blood pressure 130/72 mm Hg |
Correct Answer: A,B,C,D,E,F,G
Rationale: Resolution of shaking, flushing, itching, anxiety, and normalization of vital signs indicate recovery from the adverse drug reaction.
Extract:
Question 3 of 5
The nurse administers naloxone to a client with opioid-induced respiratory depression. One hour later, nursing assessment reveals that the client has a respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and is unable to be aroused. Which action should the nurse implement?
Correct Answer: C
Rationale: Naloxone reverses opioid effects. Persistent respiratory depression suggests the need for a second dose to counteract ongoing opioid toxicity.
Question 4 of 5
A client has a prescription for heparin 5000 units IV STAT. Several pre-filled syringes of low molecular weight heparin are available in the client's medication drawer. Which action should the nurse implement?
Correct Answer: D
Rationale: Low molecular weight heparin and unfractionated heparin are not interchangeable. The nurse must obtain the correct heparin form as prescribed.
Question 5 of 5
A client who is newly diagnosed with diabetes insipidus (DI) is receiving synthetic vasopressin intravenously. Which side effect of vasopressin reported by the client should the nurse report to the healthcare provider?
Correct Answer: D
Rationale: Worsening headache may indicate water intoxication or hyponatremia, serious complications of vasopressin requiring immediate attention.