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Ati Rn Adult Medical Surgical 2023 Proctored Exam
Total Questions : 97
Showing 10 questions, Sign in for more2200: Client admitted from the ED. Client has a history of CHF and type 1 diabetes mellitus. Client presented to ED with shortness of breath, bilateral lower extremity edema, and a weight gain of 3 kg (6.6 lb) in the past 2 days. The client was given 2 L of O2 via nasal cannula and a peripheral IV was established in the left antecubital. The client was administered 80 mg of IV furosemide prior to leaving the ED for admission.
0100: The client reports dizziness, especially when getting up from the bed to go to the bathroom. Client also reports thirst. Lung sounds are clear. Bilateral pedal pulses are +1.
2200:
- Temperature 37.2° C (99° F)
- Heart rate 89/min
- Respiratory rate 28/min
- Blood pressure 175/88 mm Hg
- Oxygen saturation 95% on 2 L via nasal cannula
0100:
- Temperature 36.9°C (98.4° F)
- Heart rate 105/min
- Respiratory rate 16/min
- Blood pressure 122/75 mm Hg
- Oxygen saturation 92% on 2 L via nasal cannula
Urine Output
- 2300: 500 mL
- 0000: 450 mL
- 0100: 30 mL
A nurse on a medical-surgical unit is caring for a client who has a history of congestive heart failure (CHF).
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 Choices:
- Hypovolemic shock: The client has received a high dose of IV diuretic (furosemide) and has drastically reduced urine output (30 mL in 1 hour), dizziness, and hypotension (BP dropped from 175/88 to 122/75 mm Hg). These are signs of intravascular volume depletion leading to hypovolemic shock.
- Administer IV fluids: This helps to restore circulating volume and prevent progression to shock. It improves perfusion to vital organs.
- Elevate the client's feet: This (Modified Trendelenburg) helps increase venous return to the heart and improve cardiac output during a hypotensive crisis.
- Pulse pressure: A narrowing pulse pressure (the difference between systolic and diastolic BP) is a classic sign of compensatory hypovolemic shock.
- Mental status: Changes in level of consciousness or increased confusion are early indicators of decreased cerebral perfusion in shock.
Rationale for Incorrect Choices:
- Septic Shock: While the client has diabetes (a risk factor for infection), there are no clinical indicators of infection such as an elevated temperature or a history of fever. The 0100 temperature of 36.9°C (98.4°F) is normal.
- Obstructive Shock: This is caused by a physical obstruction to blood flow (like a tension pneumothorax or pulmonary embolism). The client's lung sounds are clear, and the clinical history specifically points to rapid fluid loss via diuresis rather than an obstructive event.
- Cardiogenic Shock: Although the client has CHF, cardiogenic shock usually presents with pulmonary congestion (crackles) and signs of pump failure. At 0100, the client’s lung sounds are clear and they are experiencing signs of dehydration (thirst, dizziness) after receiving 80 mg of IV furosemide, which indicates the low blood pressure is due to low volume (hypovolemia), not primary pump failure.
- Administer 1 unit of packed RBCs: This is indicated for hemorrhagic shock (blood loss). This client is losing fluid through urine (980 mL in 3 hours), not blood.
- Administer IV antibiotics: This would be the priority for septic shock. There is no evidence of infection in the provided notes or vitals.
- Obtain a lactate level: While lactate is a common lab for shock, it is specifically the "gold standard" for identifying tissue hypoperfusion in sepsis. In a clear case of over-diuresis leading to hypovolemia, the immediate priority is volume replacement.
- Blood culture: This is used to diagnose sepsis/septic shock, which is not supported by the client's clear lung sounds and normal temperature.
- Temperature: While important, it is not a specific indicator for monitoring progress in hypovolemic shock treatment; it is more relevant for infection.
- Platelet count: This would be monitored if the nurse suspected a clotting disorder or DIC (disseminated intravascular coagulation), often seen in advanced sepsis, but it does not help assess fluid resuscitation progress.
A nurse is caring for a client who takes lisinopril for hypertension. Which of the following client statements indicates an adverse effect of the medication?
Diverticular disease
Cardiovascular disease
Type 2 diabetes mellitus
1000:
Admitted for abdominal pain. Pain reported as 8 on scale of 0 to 10. Pain located in the left lower quadrant. Nausea and vomiting present. Guarded movement and abdominal distention present.
1100:
Pain reported as 10 on a scale of 0 to 10. Blood specimen sent for CBC analysis.
CT ordered.
1245:
WBC count 14,000/mm3 (5,000 to 10,000/mm3)
RBC count 5.2 million/mm3 (4.2 to 6.1 million/mm3)
Hemoglobin 15 g/dL (12 to 18 g/dL)
Hematocrit 45% (37% to 52%)
Platelets 250,000/mm3 (150,000 to 400,000/mm3)
CT shows thickening of the bowel in the left lower quadrant, indicating possible diverticulitis.
1015:
- Temperature 38.3° C (101° F)
- Heart rate 99/min
- Respiratory rate 14/min
- Blood pressure 136/80 mm Hg
- Oxygen saturation 98% on room air
1100:
- Temperature 38.8" C (101.8° F)
- Heart rate 115/min
- Respiratory rate 15/min
- Blood pressure 148/90 mm Hg
- Oxygen saturation 99% on room air
A nurse is caring for a client who reports abdominal pain.
The nurse is caring for a client who has abdominal pain. Which of the following actions should the nurse take? Select all that apply.
Metoprolol 50 mg PO twice daily
Furosemide 40 mg PO daily
Potassium chloride 20 mEq/L PO twice daily
Sodium 145 mEq/L (136 to 145 mEq/L)
Potassium 3.8 mEq/L (3.5 to 5 mEq/L)
Calcium 10.2 mg/dL (9 to 10.5 mg/dL)
WBC count 7,000/mm3 (5,000 to 10,000/mm3)
Brain natriuretic peptide (BNP) 400 pg/mL (less than 100 pg/mL) Echocardiogram Atrial fibrillation
Day 1:
- Temperature 37.1° C (98.8° F)
- Heart rate 110/min
- Respiratory rate 22/min
- Blood pressure 148/80 mm Hg
- Oxygen saturation 93% on 2 L/min via nasal cannula
- Weight upon admission 85.9 kg (189 lb)
Day 2:
- Temperature 37° C (98.6" F)
- Heart rate 112/min
- Respiratory rate 20/min
- Blood pressure 146/82 mm Hg
- Oxygen saturation 90% on 2 L/min via nasal cannula
- Weight 87.7 kg (193 lb)
A nurse is caring for a client who has heart failure.
After reviewing the findings, which of the following actions should the nurse take?
For each potential provider's prescription, click to specify if the prescription is anticipated, nonessential, or contraindicated for the client.
Explanation
- Decrease the client's oxygen to 1 L/min via nasal cannula: The client’s oxygen saturation dropped to 90% on 2 L/min, so decreasing oxygen could worsen hypoxia. This prescription is nonessential/unsafe.
- Begin a 24-hr urine collection for the client: Routine 24-hour urine collection is not required for heart failure management unless assessing renal function for a specific indication; therefore, nonessential.
- Restrict the client's fluid intake to 2 L per day: Fluid restriction is anticipated in clients with heart failure to help manage fluid overload, especially given the 1.8 kg (4 lb) weight gain in 24 hours.
- Hold the client's metoprolol: The client has atrial fibrillation and hypertension, and beta-blockers are essential for rate control and reducing cardiac workload; holding the medication is contraindicated unless specifically ordered for a critical adverse event.
- Increase the dosage of furosemide: The client shows signs of fluid overload (weight gain, decreased oxygen saturation, elevated BNP). Increasing the diuretic dose is anticipated to manage fluid retention.
- Weigh the client daily: Daily weights are anticipated in heart failure management to monitor fluid status and guide therapy.
A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)?
A nurse is assessing a client following the insertion of a central venous catheter. Which of the following findings indicates a pneumothorax?
A nurse is reviewing a client's cardiac monitor for dysrhythmias. Which of the following findings should the nurse identify as an indication for the placement of a permanent pacemaker?
A home health nurse is teaching a client who has heart failure. Which of the following responses should the nurse identify as an indication that the client understands the teaching?
A nurse is caring for a client who is postoperative following a total knee arthroplasty. The client tells the nurse. "I will not be able to play with my grandchildren anymore." Which of the following responses should the nurse make?
A nurse is caring for an older adult client who is 1 hr postoperative following a transurethral resection of the prostate and is receiving continuous bladder irrigation. Which of the following findings should the nurse report to the provider?
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