ATI RN
ATI Advanced Med Surg Final Exam 0924 Questions
Extract:
Vital signs
Blood pressure 180/90 mm Hg
Heart rate 105/min
Temperature 37.1° C (98.8° F)
Respirations 18min; labored
Pulse oximetry 94 on 2L nasal cannula%
Nurses notes
The client reports worsening fatigue over the last 3 days. The client also reports loss of appetite, denies nausea or vomiting.
On assessment, the client appears pale, lung and heart sounds within defined limits. Abdomen is tender in area of incision from transplant. Bowel sounds are hypoactive in all 4 quadrants. Bilateral pedal pulses +2. +1 edema in bilateral lower extremities. Client reports that for the last 2 days they have only urinated twice per 24-hour period.
Medical history
History of coronary artery disease
Type 2 diabetes mellitus
Renal failure
Renal transplant 6 weeks ago
Diagnostic Results
BUN 25 mg/dL (10 to 20 mg/dL)
Creatine 2.0 mg/dL (0.5 to 1.3 mg/dL)
Hemoglobin 15 mmol/L (12 to 18 mmol/L)
Hematocrit 45% (37% to 52%)
Potassium 5.2 mEq/L (3.5 to 5.0 mEq/L)
Sodium 145 mEq/L (136 to 145 mEq/L)
Question 1 of 5
Which of the following findings indicate that the client may be experiencing transplant rejection? (Select all that apply.)
Correct Answer: D,E
Rationale: Elevated creatinine and signs at the incision site indicate possible kidney transplant rejection.
Extract:
Question 2 of 5
A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?
Correct Answer: C
Rationale: Decreased level of consciousness is a direct sign of increased intracranial pressure affecting brain function.
Question 3 of 5
A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the postoperative period?
Correct Answer: B
Rationale: Performing neurovascular checks of the extremities is the most important action to detect complications such as compartment syndrome or impaired circulation.
Question 4 of 5
A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a myocardial infarction? (Select all that apply.)
Correct Answer: A,C,D
Rationale: Myoglobin is an early biomarker for myocardial injury and can be used for initial detection of myocardial infarction. Troponin T and Troponin I are highly specific biomarkers for myocardial infarction and are used to confirm the diagnosis of an MI.
Question 5 of 5
A nurse is performing pulmonary hygiene for a client who has pneumonia and positions the client on his left side in Trendelenburg position. From which of the following lung segments should the nurse expect secretions to be mobilized with this position?
Correct Answer: A
Rationale: Placing the client on the left side in Trendelenburg position promotes drainage from the right lower lobe's lateral segment by using gravity to mobilize secretions.