ATI RN
ATI Med Surg Pharm Comprehensive Exam 1 Questions
Extract:
Diagnostic Results
0900:
Hct 27% (37% to 47%)
Hgb 8 g/dL (12 g/dL to 16 g/dL)
WBC 7,000/mm3 (5000 to 10,000/mm3)
Potassium 4.2 mEq/L (3.5 mEq/L to 5 mEq/L)
Nurses' Notes
1000:
1 unit of packed RBCs started through a #18 g IV in right hand as prescribed. Unit of blood infusing well. IV site dry and intact, without redness or swelling.
1015:
Client appears anxious and reports a headache and low back pain. Client voided 100 mL of brown-colored urine. Bilateral breath sounds clear and present throughout.
Vital Signs
1000:
Temperature 37.2° C (99° F)
Blood pressure 106/56 mm Hg Heart rate 104/min
Respiratory rate 20/min
Pulse oximetry 96% on room air
1015:
Temperature 39.6" C(103.3° F)
Blood pressure 74/50 mm Hg
Heart rate 124/min
Respiratory rate 28/min
Pulse oximetry 95% on room air
Question 1 of 5
Which of the following findings at 1015 requires further action? (Select all that apply.)
Correct Answer: C,D
Rationale: Brown-colored urine can sometimes indicate dehydration or certain medical conditions, requiring follow-up. A significant drop in blood pressure (74/50 mmHg) indicates hypotension and requires immediate attention.
Extract:
Question 2 of 5
A nurse is observing a newly licensed nurse prepare a sterile field. For which of the following actions should the nurse intervene?
Correct Answer: C
Rationale: Holding a bottle of solution with the label away from the palm of the hand is incorrect; the label should be held toward the palm to protect it from damage caused by spills.
Question 3 of 5
A nurse is teaching a group of clients about tick-borne illnesses. Which of the following information should the nurse include in the teaching regarding ticks?
Correct Answer: C
Rationale: Grasping the tick as close to the skin as possible with fine-tipped tweezers allows for complete removal without squeezing the tick's body.
Question 4 of 5
A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse?
Correct Answer: D
Rationale: Palpating the abdomen prior to auscultation can alter bowel sounds, making it important to auscultate before palpation.
Question 5 of 5
A nurse withdraws morphine 2 mg from a 4-mg/mL vial to inject IM for a client. Which of the following actions should the nurse take for wasting the excess medication?
Correct Answer: D
Rationale: Having a second nurse witness the disposal of the excess medication ensures proper documentation and accountability for controlled substances.