ATI RN
ATI Advanced Med Surg Exam 3 Questions
Extract:
Question 1 of 5
The rapid response team (RRT) is caring for a client with asystole. Which nursing statement made to the client's family about the actions of the RRT is appropriate?
Correct Answer: D
Rationale: Asystole is not defibrillatable, so the RRT continues CPR, and this statement accurately informs the family.
Question 2 of 5
A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.)
Correct Answer: A,B,C,D,E
Rationale: The sequence follows the ABCDE trauma survey: open airway (
C), assess breathing (
B), establish IV for circulation (
D), assess neurological status (E), and expose for assessment (
A).
Question 3 of 5
A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia?
Correct Answer: A
Rationale: Atropine increases heart rate by blocking vagal tone, making it the first-line treatment for symptomatic bradycardia.
Question 4 of 5
A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?
Correct Answer: B
Rationale: Cheyne-Stokes respirations involve alternating hyperventilation and apnea, often seen in neurological or heart failure conditions.
Extract:
Medical History
Client was brought to the ED by their family member due to mental status changes. The family member reports that they visit the client every other day and today the client did not initially realize who they were until several minutes after talking with them. The client has diabetes mellitus and takes insulin daily. A wound is noted on the right foot.
Nurses' Notes
Family member reports that the client did not initially realize who they were when they went to visit. Client is currently somnolent but rouses to verbal stimuli and is oriented to person. Glascow coma score is 13 and Modified Early Warning System (MEWS) score is 6. Respirations are even. unlabored and deep, with few crackles noted in lung bases bilaterally with auscultation. Mucous members are dry and pink. Abdomen soft with hypoactive bowel sounds. Radial and pedal pulses are palpable, no edema noted.
Skin is warm and dry. The right foot has a 2.5 cm x 3.3 cm (1 in x 1.3 in) superficial wound to the ball of the foot. The wound is moist with a scant amount of purulent drainage. Client stated they stepped on something last week while walking but did not notice a wound had occurred.
Client's family member reports that the client takes 10 units of regular insulin subcutaneously every morning and 5 units every evening with last dose taken this am. Also states that the client took two aspirin yesterday for a headache.
Vital Signs
Temperature 38.5°C (101.3° F) Pulse 110/min
Blood pressure 98/60 mm Hg Respiratory rate 26/min
Oxygen saturation 93% on 2 L nasal cannula
Diagnostic Results
RBC count 5.0 (Male 4.7 to 6.1)
WBC count 9,500 mm3 (5,000 to 10,000/mm3) Platelets 97,000/mm3 (150,000 to 400,000/mm3) Hemoglobin 15 g/dL (Male 14 to 18 g/dL)
Hematocrit 45% (Male 42% to 52%; Female 37% to 47%) Glucose 186 mg/dL (74 to 106 g/dL)
Question 5 of 5
It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications?
Correct Answer: C,D,E,F
Rationale: Administering antibiotics targets the infection, measuring lactate assesses tissue perfusion, fluid resuscitation restores volume, and blood cultures identify the causative organism, all critical within the first hour of sepsis management.