Review Ati W25 Nurs 226 Med Surg Proctored Exam

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Ati W25 Nurs 226 Med Surg Proctored Exam

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Total Questions : 82

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Question 1:

A nurse is assessing a client with acute pancreatitis. Which of the following findings should be the nurse's highest priority?

A. Fever B. Hypotension C. Abdominal distention D. Elevated serum lipase levels

Answer and Explanation

Choice A:

Fever is a common finding in acute pancreatitis and may indicate inflammation or infection. While it is clinically significant and should be monitored, it does not immediately threaten circulation or oxygen delivery. Therefore, it is not the highest priority compared to signs of hemodynamic instability.

Choice B:

Hypotension is the highest priority because it indicates potential hypovolemia, third-spacing of fluids, or shock—serious complications of acute pancreatitis. Pancreatitis can cause massive fluid shifts into the retroperitoneal space, leading to decreased circulating blood volume and impaired organ perfusion. According to the ABCs (Airway, Breathing, Circulation) and priority frameworks, compromised circulation and signs of shock require immediate intervention to prevent organ failure and death.

Choice C:

Abdominal distention is expected in acute pancreatitis due to inflammation, ileus, and fluid accumulation. Although it requires monitoring and can indicate worsening condition, it is not immediately life-threatening unless accompanied by respiratory compromise or severe hemodynamic instability.

Choice D:

Elevated serum lipase levels confirm the diagnosis of pancreatitis and help assess severity, but this is a laboratory finding—not an immediate life-threatening clinical manifestation. Lab abnormalities are important for diagnosis and monitoring but do not take priority over unstable vital signs.

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Question 2:

A client, diagnosed with acute pancreatitis 5 days ago, is experiencing respiratory distress. Which assessment finding is the greatest concern?

A. PaO2 of 46 mm Hg (80-100 mm Hg) B. lack of adventitious lung sounds C. respirations of 20 breaths/min (12-20 breaths/min) D. oxygen saturation of 95% on room air (95-100%)

Answer and Explanation

Choice A:

A PaO₂ of 46 mm Hg is critically low and indicates severe hypoxemia. Normal PaO₂ ranges from 80–100 mm Hg. A value of 46 mm Hg reflects significant impairment in oxygen exchange and can lead to tissue hypoxia, organ failure, and death if not treated immediately. Acute pancreatitis can lead to acute respiratory distress syndrome (ARDS) due to systemic inflammation and capillary leakage in the lungs. According to airway, breathing, and circulation (ABC) priority principles, impaired oxygenation is an immediate life-threatening condition and is the greatest concern.

Choice B:

Lack of adventitious lung sounds is not necessarily abnormal. Clear lung sounds can be present even in early respiratory compromise. The absence of crackles, wheezes, or rhonchi does not rule out hypoxemia. Therefore, this finding is not as concerning as a critically low PaO₂.

Choice C:

A respiratory rate of 20 breaths per minute is at the upper limit of normal (12–20 breaths/min). While it may suggest mild compensation or anxiety, it is not immediately life-threatening and does not indicate severe respiratory compromise by itself.

Choice D:

An oxygen saturation of 95% on room air is within normal limits. Although it should be monitored closely in a client with respiratory distress, this value alone does not indicate acute deterioration.

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Question 3:

The nurse assesses a client with cirrhosis who is prescribed diuretics for ascites. Which assessment findings are most important for the nurse to evaluate related to diuretic therapy? Select all that apply.

A. Renal function tests. B. Body image disturbances. C. Gastrointestinal bleeding D. Electrolyte laboratory results. E. increased clotting tendencies.

Answer and Explanation

Choice A:

Renal function tests are essential to monitor in a client with cirrhosis receiving diuretics (such as spironolactone or furosemide). Diuretics increase urine output and can reduce circulating volume, potentially leading to dehydration and renal impairment. Clients with cirrhosis are already at risk for hepatorenal syndrome. Monitoring BUN and creatinine helps detect worsening kidney function early and prevents serious complications. This is directly related to diuretic therapy and is a priority.

Choice B:

Body image disturbances may occur due to ascites and abdominal distention, but this is a psychosocial concern related to the disease process itself—not a direct effect of diuretic therapy. While important for holistic care, it is not a priority assessment specific to medication safety.

Choice C:

Gastrointestinal bleeding is a serious complication of cirrhosis (often due to varices), but it is not directly caused by diuretic therapy. Monitoring for GI bleeding is important in cirrhosis overall; however, it is not specifically related to evaluating the effects or safety of diuretics.

Choice D:

Electrolyte laboratory results are critically important when a client is taking diuretics. Diuretics can cause significant electrolyte imbalances such as hypokalemia (with loop diuretics) or hyperkalemia (with potassium-sparing diuretics like spironolactone). Sodium levels may also decrease. Electrolyte disturbances can lead to cardiac dysrhythmias and neurological changes, making this a priority safety concern.

Choice E:

Increased clotting tendencies are not expected in cirrhosis; in fact, clients with cirrhosis are more likely to have decreased clotting due to reduced production of clotting factors by the liver. This finding is unrelated to diuretic therapy and is not a priority assessment in this context.

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Question 4:

A nurse is assessing a client with acute pancreatitis who reports increased shortness of breath and has an oxygen saturation level of 88%. What should the nurse assess first?

A. Neurological status for changes in level of consciousness B. Lung sounds for the presence of crackles or diminished breath sounds. C. Abdominal girth and tenderness D. Vital signs for hypotension and tachycardia.

Answer and Explanation

Choice A:

Neurological status is important to assess, as hypoxemia can lead to confusion or altered mental status. However, this is a secondary assessment after identifying and addressing the primary cause of hypoxemia. It is not the first action.

Choice B:

Lung sounds should be assessed first because the client is experiencing shortness of breath with a low oxygen saturation (88%, below the normal 95–100%). In acute pancreatitis, respiratory complications such as pleural effusion or acute respiratory distress syndrome (ARDS) can develop. Assessing lung sounds immediately helps determine the cause of hypoxemia, guides oxygen therapy, and identifies the need for urgent interventions like supplemental oxygen or respiratory support.

Choice C:

Abdominal girth and tenderness are relevant for monitoring pancreatitis progression and ascites, but these assessments do not directly address the acute respiratory compromise. They are not the first priority in a client with hypoxemia.

Choice D:

Vital signs for hypotension and tachycardia are important because circulatory instability can worsen oxygen delivery. While vital signs should be checked promptly, auscultating lung sounds provides more specific information about respiratory compromise, which is the immediate priority in a client with low oxygen saturation.

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Question 5:

The nurse cares for a client with cirrhosis who is experiencing variceal bleeding. What should the nurse do first?

A. Obtain a type and crossmatch for blood administration B. Insert two large bore intravenous lines C. Suction the airway D. Prepare the client for endoscopy

Answer and Explanation

Choice A:

Obtaining a type and crossmatch is necessary for blood transfusion in variceal bleeding, but this is not the immediate first action. Stabilizing the airway takes precedence over preparing for transfusion.

Choice B:

Inserting two large-bore IV lines is important for rapid fluid or blood replacement, but it comes after ensuring the airway is clear and the client can oxygenate effectively. IV access alone does not prevent hypoxia.

Choice C:

Suctioning the airway is the first priority. Clients with variceal bleeding are at risk for vomiting large amounts of blood, which can obstruct the airway and cause aspiration or hypoxemia. According to the ABC (Airway, Breathing, Circulation) priority framework, maintaining a patent airway is always the first action in emergencies.

Choice D:

Preparing the client for endoscopy is essential for definitive treatment of variceal bleeding, but this is not the immediate priority. The client must first be stabilized—airway maintained, breathing supported, and circulation ensured—before diagnostic or therapeutic procedures.

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Question 6:

The nurse suspects that a client who presented to the emergency department is experiencing bleeding from liver trauma, Which cues support the nurse's suspicion? Select all that apply.

A. New onset of lightheadedness B. Complaints of right shoulder pain C. Heart rate of 116 beats per minute D. Requesting more water to drink E. A wide pulse pressure F. Respiratory rate of 28 breaths per minute

Answer and Explanation

Choice A:

New onset of lightheadedness is a key sign of hypovolemia due to internal bleeding. Blood loss decreases circulating volume, leading to decreased perfusion to the brain and dizziness or syncope. This supports the suspicion of internal hemorrhage from liver trauma.

Choice B:

Complaints of right shoulder pain (Kehr’s sign) can indicate referred pain from diaphragmatic irritation due to blood in the peritoneal cavity, commonly associated with liver or spleen trauma. This is an important clinical cue supporting internal bleeding.

Choice C:

Heart rate of 116 beats per minute indicates tachycardia, a compensatory response to hypovolemia. The body increases heart rate to maintain cardiac output when blood volume decreases, which is consistent with bleeding.

Choice D:

Requesting more water to drink is not directly related to liver trauma or internal bleeding. While thirst may occur with mild fluid loss, it is nonspecific and not a reliable cue for acute hemorrhage.

Choice E:

A wide pulse pressure (the difference between systolic and diastolic BP) is not typically associated with acute hemorrhage. In early blood loss, blood pressure is often normal or low-normal, and pulse pressure may narrow, not widen.

Choice F:

Respiratory rate of 28 breaths per minute indicates tachypnea, which can occur as a compensatory mechanism for hypovolemia and tissue hypoxia. Increased respiratory rate helps improve oxygen delivery when perfusion is compromised due to bleeding.

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Question 7:

A student nurse is completing an internship in the emergency department. The student asks the preceptor. "How is emergency department nursing different from other areas of nursing practice? How should the experienced emergency department nurse respond? Select all that apply.

A. "We focus on primary care." B. "Most of what we do is acute care or critical care." C. "Emergency department nurses provide care to patients of all ages." D. "Most of the time we are providing care to patients without a medical diagnosis." E. "it is episodic

Answer and Explanation

Choice A:

Emergency department (ED) nursing focuses on acute, urgent, or emergent care, not routine primary care. Primary care involves preventive, long-term, and health maintenance services, which are outside the ED scope.

Choice B:

ED nurses manage sudden, severe illnesses or injuries that require rapid assessment, stabilization, and intervention. This differentiates ED nursing from units providing routine or chronic care.

Choice C:

ED nurses see neonates, children, adults, and older adults in the same shift, which requires broad knowledge across the lifespan.

Choice D:

Patients often arrive with symptoms rather than confirmed diagnoses, requiring ED nurses to perform rapid assessments, triage, and initiate interventions without full diagnostic information.

Choice E:

ED care is short-term and focused on immediate stabilization and treatment. Once the patient is stabilized, they may be discharged, admitted, or transferred to another unit—care is usually not ongoing long-term management.

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Question 8:

A nurse manager is making morning assignments for the nursing team. Which duties can be assigned to the nursing assistant/unlicensed worker? Select all that apply.

A. Changing the linen of a client on a pressure-releasing mattress B. Repositioning a client on complete bed rest C. Teaching a client on an anticoagulant about using an electric razor D. Transferring a client from the bed to the chair using a mechanical lift E. Totaling the oral intake and output for the entire unit.

Answer and Explanation

Choice A:

Primary care involves ongoing management of chronic diseases, preventive screenings, routine health maintenance, and long-term patient relationships. Emergency department (ED) nursing differs because patients present with acute illnesses, injuries, or exacerbations, often requiring immediate stabilization. The ED is not a setting for preventive or longitudinal care, so focusing on primary care does not reflect the role of the ED nurse.

Choice B:

ED nurses provide rapid assessment, monitoring, and intervention for patients with life-threatening or emergent conditions such as trauma, myocardial infarction, stroke, sepsis, or respiratory distress. This requires advanced clinical skills, critical thinking, and the ability to prioritize interventions quickly. Unlike med-surg or outpatient units, where patients often have known diagnoses and stable conditions, the ED often deals with unstable patients whose status can deteriorate rapidly.

Choice C:

ED nurses care for neonates, children, adults, and older adults—sometimes all in the same shift. This requires knowledge of age-specific assessments, vital signs, medication dosages, and communication techniques. In contrast, many nursing units specialize in a specific age group, such as pediatrics or geriatrics.

Choice D:

Patients usually present with symptoms rather than confirmed diagnoses, such as chest pain, shortness of breath, abdominal pain, or altered mental status. ED nurses must perform rapid and accurate assessments, interpret diagnostic tests, anticipate complications, and implement interventions without having the full picture. This level of uncertainty distinguishes ED nursing from units where the diagnosis is already established.

Choice E:

Care in the ED is typically short-term and focused on stabilization. Once patients are stabilized, they are discharged, admitted, or transferred to another unit. ED nurses do not usually provide long-term follow-up or chronic disease management. This episodic nature contrasts with inpatient med-surg or primary care, where nurses often develop longitudinal care plans and maintain continuity of care.

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Question 9:

A client is admitted to the emergency department with abdominal pain. Which data should the nurse document regarding a client's complaint of abdominal pain? Select all that apply.

A. The client describes the pain as sharp and stabbing B. The pain began 24 hours ago C. The client fears losing her job if pain causes another absence D. Belching has lessened the pain E. Walking exacerbates the pain

Answer and Explanation

Choice A:

The quality of pain is essential information. Terms like sharp, stabbing, cramping, or dull help guide differential diagnosis and treatment planning. This is a core component of a pain assessment.

Choice B:

Onset and duration are critical for identifying acute versus chronic conditions and establishing a timeline for the development of symptoms. This helps prioritize diagnostic testing and interventions.

Choice C:

Although psychosocial concerns are important to consider for holistic care, they do not describe the pain itself and are not part of a focused pain assessment. This is contextual information, not clinical data related to the abdominal pain.

Choice D:

Relieving factors provide valuable information about what alleviates symptoms and may suggest gastrointestinal causes (e.g., gas or reflux). This is part of the standard pain assessment (OLDCART).

Choice E:

Aggravating factors are also important to document, as they help identify triggers or contributing factors and guide interventions, such as positioning, activity restrictions, or further evaluation.

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Question 10:

Which client admitted to the emergency department should the nurse see first?

A. A client with a blood pressure of 170/95 mm Hg B. A client experiencing a "ripping" sensation in the chest. C. A client taking anticoagulants with bloody stool. D. A client with a urine output of 240 mL in 12 hours.

Answer and Explanation

Choice A:

While this indicates hypertension, it is not immediately life-threatening unless accompanied by other symptoms such as chest pain, shortness of breath, or neurological changes. This client requires assessment and possible intervention but is not the highest priority.

Choice B:

A “ripping” or tearing chest pain is highly suggestive of an aortic dissection, a life-threatening emergency. This condition can rapidly lead to aortic rupture, cardiac tamponade, or death. According to the ABC and Maslow priority frameworks, this client requires immediate assessment and intervention, making them the highest priority.

Choice C:

This indicates gastrointestinal bleeding, which can be serious, especially in patients on anticoagulants, but the client is likely hemodynamically stable if vital signs are not provided. While urgent, it is not more immediately life-threatening than a suspected aortic dissection.

Choice D:

This is oliguria and may indicate early renal compromise, but it is not an immediate threat to life compared to suspected aortic dissection. This client should be assessed promptly but after addressing the highest-risk patient

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Ati W25 Nurs 226 Med Surg Proctored Exam

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