ATI RN
ATI Nur258 Med Surg 2 Final Exam Questions
Extract:
Nurses Notes
Day 1:
Client is admitted with a 2-day history of headache, muscle aches, fever, sore throat, and fatigue.
Vital Signs
1200:
Temperature: 39.5°C (103.1°F)
Blood pressure: 128/56 mm Hg
Heart rate: 112/min
Respiratory rate: 22/min
SpO2: 96% on room air
1300:
Temperature: 39.9°C (103.8°F)
Blood pressure: 128/56 mm Hg
Heart rate: 112/min
Respiratory rate: 22/min
SpO2: 96% on room air
Diagnostic Results
1200:
Temperature: 39.5°C (103.1°F)
Blood pressure: 128/56 mm Hg
Heart rate: 112/min
Respiratory rate: 22/min
SpO2: 96% on room air
1300:
Temperature: 39.9°C (103.8°F)
Blood pressure: 128/56 mm Hg
Heart rate: 112/min
Respiratory rate: 22/min
SpO2: 96% on room air
Question 1 of 5
Which of the following actions should the nurse take? (Select all that apply.)
Correct Answer: A,B,D
Rationale: Encouraging fluid intake prevents dehydration. Wearing a mask prevents influenza spread. A private room reduces transmission risk.
Extract:
Question 2 of 5
The nurse is caring for a client in neurogenic shock following an overdose of anti-anxiety medication. When assessing this client, the nurse should recognize what characteristic of neurogenic shock?
Correct Answer: D
Rationale: Bradycardia is a hallmark of neurogenic shock due to unopposed parasympathetic stimulation resulting from the loss of sympathetic nervous system control.
Question 3 of 5
A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the healthcare provider?
Correct Answer: A
Rationale: Difficulty swallowing in a client with facial burns can indicate airway compromise due to edema and should be reported immediately as it may require urgent intervention to secure the airway.
Question 4 of 5
A nurse is teaching a student nurse about the effects of vasopressin that is prescribed for a client with diabetes insipidus. Which statement by the student nurse indicates an understanding of the teaching?
Correct Answer: D
Rationale: Vasopressin acts to decrease urine output by increasing water reabsorption in the kidneys, which helps manage diabetes insipidus.
Extract:
Nurses notes
Day 1:
Place the client on
Client reports fatigue, weight loss, and anorexia. Chemotherapy started as prescribed.
droplet precautions.
4 weeks later:
Client reports sore mouth and increased fatigue. Multiple bruises noted on elbows and legs.
Voided 350 mL of clear yellow urine.
Diagnostic results
Day 1:
Hematocrit (Hct) 38% (nl. 36-48%)
Hemoglobin (Hgb) 13 g/dL (nl. 12-16 g/dL)
Platelet 180,000/mm3 (nl. 150,000-400,000/mm3)
Total white blood cell (WBC) count 7000/mm3 (nl. 5,000-10,000/mm3)
4 weeks later:
Hct 35% (nl. 36-48%)
Hgb 11 g/dL (nl. 12-16 g/dL)
Platelet 100,000/mm3 (nl. 150,000-400,000/mm3)
Total WBC count 3000/mm3 (nl. 5,000-10,000/mm3)
with 0.9% sodium chloride every 4 hrs.
Question 5 of 5
For each potential healthcare provider's prescription at 4 weeks, click to specify if the prescription is anticipated, nonessential, or contraindicated for the client.
Correct Answer: A,C,E
Rationale: Placing the client on droplet precautions is anticipated to prevent infection in immunocompromised patients. A private room is anticipated to reduce infection risk. Rinsing the client's mouth with 0.9% sodium chloride is anticipated to manage sore mouth and maintain oral hygiene.