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Ati rn adult medical surgical 2023
Total Questions : 86
Showing 10 questions, Sign in for moreA nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan of care?
Client comes to the ED reporting I headache that has lasted for 3 days. Reports pain is currently a 7 out of 10. Client appears pale and lethargic. Client also reports photophobia, malaise, nausea, and chills. Positive nuchal rigidity, lung sounds clear, heart sounds regular, hyperactive bowel sounds in all 4 quadrants. 18-gauge IV initiated in the left antecubital space and IV fluids started. Awaiting CT scan results.
- Temperature 39.2° C (102.6° F)
- Heart rate 115/min
- Respiratory rate 12/min
- Blood pressure 98/64 mm Hg
- Oxygen saturation 94% on room air
A nurse is caring for a client who has just been admitted to the emergency department (ED).
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Explanation
Rationale for Correct Answers:
- Meningitis: The client exhibits classic signs of meningitis, including headache, photophobia, nuchal rigidity, nausea, chills, and fever. These symptoms point to central nervous system infection, not a primary vascular or surgical issue.
- Decrease environmental stimuli: Photophobia is a common feature of meningitis due to meningeal irritation. Reducing environmental stimuli such as bright lights and noise helps minimize discomfort and prevent further neurological stress.
- Initiate neurological checks every 2 hr: Frequent neuro assessments are necessary in meningitis to monitor for early signs of increased intracranial pressure, declining mental status, or cranial nerve involvement. Early detection of deterioration is crucial for timely intervention.
- Temperature: Monitoring temperature is essential because it reflects the client’s response to infection and treatment. Persistent fever may indicate ongoing infection or complications, while normalization suggests clinical improvement.
- Lactate level: Elevated lactate levels may signal tissue hypoperfusion or sepsis associated with severe meningitis. Monitoring helps guide fluid resuscitation and evaluate the progression or resolution of systemic involvement.
Rationale for Incorrect Choices:
- Administer gabapentin: Gabapentin is used primarily for neuropathic pain or seizures and does not address the infectious or inflammatory nature of meningitis. It offers no benefit for the presenting symptoms and would delay appropriate treatment.
- Administer sumatriptan: Sumatriptan is indicated for migraines and works by causing vasoconstriction. It is contraindicated in infections like meningitis, where cerebral inflammation not vascular dysregulation is the underlying issue.
- Prepare the client for surgery: There is no indication for immediate surgical intervention in this case. Meningitis treatment focuses on antimicrobial therapy and supportive care unless complications like abscesses arise, which are not currently evident.
- Bowel sounds: Although documented as hyperactive, bowel sounds are not key parameters in monitoring meningitis progression. They do not provide information relevant to the infection’s severity or neurological status.
- Gait: Assessing gait is not a priority in acute meningitis care. The client is likely too ill to ambulate safely, and gait changes are not reliable indicators of meningeal or systemic improvement in the emergency phase.
- Vascular changes: While hypotension may be associated with systemic infection, "vascular changes" is a vague term and not a standard parameter to monitor in meningitis. Lactate levels provide more precise data on perfusion and sepsis risk.
A nurse is assessing a client following the insertion of a central venous catheter. Which of the following findings indicates a pneumothorax?
Type 2 diabetes mellitus
Hypertension, controlled by diuretic and ace-inhibitor therapy
Osteoarthritis
Preoperative:
- Temperature 36.4° C (97.6° F)
- Heart rate 82/min
- Respiratory rate 20/min
- Blood pressure 126/74 mm Hg
- Oxygen saturation 95% on room air
Current:
- Temperature 37.2° C (99° F)
- Heart rate 92/min
- Respiratory rate 22/min
- Blood pressure 136/85 mm Hg
- Oxygen saturation 98% on 2 L/min nasal cannula
Preoperative laboratory results:
Basic Metabolic Profile (BMP):
Glucose 190 mg/dL (74 to 106 mg/dL)
BUN 16 mg/dL (10 to 20 mg/dL)
Creatinine 0.8 mg/dL (0.5 to 1 mg/dL)
Hemoglobin A1C 9.5% (Poor diabetic control: greater than 9%)
Current laboratory results:
Basic Metabolic Profile (BMP):
Glucose 280 mg/dL (74 to 106 mg/dL)
BUN 15 mg/dL (10 to 20 mg/dL)
Creatinine 0.7 mg/dL (0.5 to 1 mg/dL)
Home medications:
Metformin 1,000 mg PO BID
Lisinopril 20 mg PO daily
Celecoxib 100 mg PO BID
A nurse is caring for a client who is postoperative following a total knee arthroplasty.
Complete the following sentence by using the lists of options.
The client is at highest risk for
Explanation
Rationale for Correct Answers:
- Wound infection: The client is at increased risk for postoperative wound infection due to poorly controlled type 2 diabetes mellitus. Elevated glucose levels impair immune function, delay wound healing, and promote bacterial growth, making infection more likely after surgery.
- Blood glucose level: The current glucose level is 280 mg/dL, and the hemoglobin A1C is 9.5%, indicating chronic poor glycemic control. This substantially increases susceptibility to infection and slows tissue recovery following total knee arthroplasty.
Rationale for Incorrect Choices:
- Deep vein thrombosis: While DVT is a concern after joint surgery, there is no evidence in the provided data (e.g., leg swelling, calf pain, or reduced mobility data) to suggest it is the most immediate risk. Other risk factors such as elevated glucose and immune suppression take precedence in this case.
- Hypovolemia: There are no signs of fluid volume deficit such as hypotension, tachycardia beyond baseline, dry mucous membranes, or poor skin turgor. The BUN and creatinine levels are within normal limits, indicating adequate fluid balance.
- Preoperative hypertension: The client’s preoperative blood pressure was within a controlled range (126/74 mm Hg), and current readings remain stable. This does not contribute significantly to an acute postoperative complication at this time.
- BUN of 15 mg/dL: A BUN of 15 mg/dL is within the normal range and does not indicate any renal impairment or fluid imbalance. It does not contribute to the highest risk condition identified in this client’s case.
0830:
Client reports feeling tightness in their chest that radiates to their left arm. Reports pain as 7 on a scale of 0 to 10.
Nitroglycerin sublingual tablet administered. Following administration of tablet, client reports chest pain as 5 on a scale of 0 to 10.
1100:
Client still reports tightness in their chest. Reports pain as 5 on a scale of 0 to 10. Client is short of breath and diaphoretic. Client states, "I feel anxious."
1200:
Thrombolytic therapy initiated.
0830:
Troponin T 0.08 ng/mL (less than 0.1 ng/mL)
Troponin I 0.01 ng/mL (less than 0.03 ng/mL)
1100:
Troponin T 0.2 ng/mL (less than 0.1 ng/mL)
Troponin I 0.1 ng/mL (less than 0.03 ng/mL)
aPTT 32 seconds (30 to 40 seconds)
Platelets 350,000/mm3 (150,000 to 400,000/mm3)
A nurse is caring for a client who has angina.
Complete the following sentence by using the lists of options.
The client is at risk for developing
Explanation
Rationale for Correct Answers:
- Myocardial infarction: The client's worsening chest pain and increasing troponin levels strongly indicate myocardial injury. Despite initial nitroglycerin, symptoms persisted, and thrombolytic therapy was started, consistent with acute MI management.
- Troponin levels: Troponin T rose from 0.08 to 0.2 ng/mL, and Troponin I from 0.01 to 0.1 ng/mL, exceeding the normal range. These cardiac biomarkers are sensitive indicators of myocardial cell damage, confirming the progression toward infarction.
Rationale for Incorrect Choices:
- Bleeding: Although thrombolytics and aPTT monitoring are related to bleeding risks, there is no current evidence of bleeding (e.g., hematuria, bruising, low platelets, or elevated aPTT). Platelets and aPTT are within normal ranges, so this is not the primary concern at this time.
- Pulmonary embolism: The client is short of breath and diaphoretic, which could be seen in PE, but there is no indication of risk factors like immobility, recent surgery, or DVT symptoms. Elevated troponins and anginal symptoms more clearly support a cardiac rather than embolic cause.
- Shortness of breath: While SOB is a significant clinical symptom, it is nonspecific and could result from anxiety, cardiac ischemia, or pulmonary causes. It does not directly confirm the most urgent diagnosis, which is best supported by objective lab data such as troponins.
- aPTT levels: The aPTT is within the expected therapeutic range and does not indicate a coagulation problem at this time. It is not a primary driver of the client's current risk status, especially in comparison to the elevated cardiac markers.
HIV type 1 (HIV-1)
Client received diagnosis of HIV-1 3 months ago. Returns to clinic today for follow-up visit and to discuss recent laboratory findings.
Upon diagnosis:
WBC count 4,500/mm3 (5,000 to 10,000/mm3)
Platelets 164,000/mm3 (150,000 to 400,000/mm3)
Sodium 139 mEq/L (136 to 145 mEq/L)
Potassium 4.2 mEq/L (3.5 to 5 mEq/L)
BUN 16 mg/dL (10 to 20 mg/dL)
3-month visit:
WBC count 4,100/mm3 (5,000 to 10,000/mm3)
Platelets 162,000 mm3 (150,000 to 400,000/mm3)
Sodium 139 mEq/L (136 to 145 mEq/L)
Potassium 3.8 mEq/L (3.5 to 5 mEq/L)
BUN 18 mg/dL (10 to 20 mg/dL)
A nurse in a health clinic is caring for a client.
Drag 1 condition and 1 client finding to fill in each blank in the following sentence.
The client is at risk for developing
Explanation
Rationale for Correct Answers:
- Infection: HIV targets and depletes CD4+ T cells, impairing immune function. A consistently low WBC count (below the normal range) indicates reduced immune defense, increasing susceptibility to infections.
- WBC count: The client’s WBC count decreased from 4,500 to 4,100/mm³, both below the normal lower limit. This progressive leukopenia in the context of HIV suggests worsening immunosuppression, which elevates the risk of opportunistic infections.
Rationale for Incorrect Choices:
- Dysrhythmias: The client’s potassium level is 3.8 mEq/L, within the normal range. Since potassium directly affects cardiac conduction, a normal level does not indicate an increased risk of dysrhythmia.
- Renal failure: The client’s BUN increased slightly from 16 to 18 mg/dL but remains within the normal range. There are no other signs of renal impairment such as elevated creatinine or abnormal electrolyte levels.
- Seizures: Sodium is stable at 139 mEq/L, which is within the normal range. Electrolyte imbalance, particularly hyponatremia, is a common trigger for seizures, which is not evident here.
- Bleeding: The platelet count is slightly decreased but still within the normal range (162,000/mm³). There is no evidence of thrombocytopenia or coagulopathy that would suggest a bleeding risk.
A nurse is planning care for a client who is experiencing seizures secondary to meningitis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)
A nurse is assessing a client who is receiving radiation therapy to the head and neck. Which of the following findings should the nurse expect?
A nurse is teaching about measures to prevent recurring urinary tract infections with a female client. Which of the following information should the nurse include in the teaching? (Select all that apply.)
A nurse is preparing to administer a blood transfusion to a client. Which of the following actions should the nurse plan to take?
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