ATI RN
ATI Nur 112 Med Surg Exam Questions
Extract:
History and Physical
Nurse Notes
Vital Signs
A 23-year-old female presents to the emergency department with altered mental status. She is accompanied by her roommate. The roommate says that symptoms started around 0900 today and have progressively worsened. She says the client first appeared euphoric but would switch to being irritable. The client also reported diarrhea and nausea. The client is combative. The client has a history of major depressive disorder and is being treated with paroxetine 50 mg PO once daily.
Question 1 of 5
Which assessment findings require follow-up by the nurse?
Correct Answer: A,B,C,D,E,H
Rationale: Myoclonus, fever, hypertension, altered mental status, tachycardia, and diaphoresis suggest serotonin syndrome, requiring immediate follow-up to manage this life-threatening condition.
Extract:
History and Physical
Nurses Notes
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 2 of 5
The nurse would determine what actions to implement in an emergent situation. The client is at immediate risk for developing:
| Necrosis |
| Cardiac arrest |
| Peripheral edema |
| Arrhythmias |
| Renal failure |
| Anaphylaxis |
Correct Answer: D,E,F
Rationale: The client's bradycardia and atrial fibrillation history increase risks for cardiac arrest and arrhythmias, while vancomycin administration poses an anaphylaxis risk.
Extract:
History and Physical
Nurse Notes
The client is a 36-year-old female with moderate persistent asthma. She takes fluticasone/salmeterol 250 mcg/50 mcg, 1 inhalation twice daily, and albuterol 90 mcg/inhalation, 2 inhalations every 4 to 6 hours PRN.
Patient Data
Exhibits
Review H and P, and nurse’s note. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.
Question 3 of 5
Review H and P, and nurse's note. Complete the diagram by specifying which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
| Place the client on a cardiorespiratory monitor |
| Administer diphenhydramine |
| Give a dose of albuterol |
| Anaphylaxis |
| Tachydysrhythmia |
| Anemia |
| Breath sounds, Airway edema |
Correct Answer: E,A,C,B,G
Rationale: The client likely has tachydysrhythmia due to albuterol overuse. Monitor with a cardiorespiratory monitor, give albuterol cautiously, and assess breath sounds and airway edema.
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 4 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:
History and Physical
Nurse Notes
Laboratory results
Flow Sheet
Orders
Client is a 24-year-old male with a 2-day history of severe vomiting and diarrhea. The client believes he has a case of food poisoning after attending a party. Other individuals at the party were having similar symptoms.
Question 5 of 5
Review H and P, nurses notes, laboratory results, flow sheet, and orders. Click to mark whether the assessment finding represents a therapeutic result of the sodium bicarbonate administered, a non-therapeutic side-effect, or an unrelated finding.
| Options | therapeutic result | non-therapeutic side-effect | unrelated finding |
|---|---|---|---|
| Capillary refill 2 seconds | |||
| Blood pressure 113/72 mm Hg | |||
| Bicarbonate 22 mEq/L (22 mmol/L) | |||
| Sodium 152 mEq/L (152 mmol/L) | |||
| 400 mL urine output | |||
| Heart rate 77 beats/minute |
Correct Answer: A,B,C,D,E,F
Rationale: Improved capillary refill, blood pressure, bicarbonate, and heart rate are therapeutic. Hypernatremia is a side effect, and urine output is unrelated.