ATI Med-Surg Exam 2 (3 Versions) 2021/2022 Graded A+
Exam 2 Version 1
1. A client who experienced a stroke on the left side of the brain suddenly begin... [Show More] s to get angry and frustrated while playing a card game. What is the best action by the rehabilitation nurse?
a. Reassure the client that there is nothing to be angry about
b. Ask the client what made him or her angry
c. Ask the client to stop behaving inappropriately
d. Distract the client
2. Admission vital signs for a brain-injured client are blood pressure 128/68 mm Hg, pulse of 110 BPM, and respirations of 26. Which set of vital signs, if taken 1 hour after admission, will be of the most concern to the nurse?
a. BP 154/68 mm Hg, Pulse 56 BPM, RR 12
b. BP 134/72 mm Hg, Pulse 90 BPM, RR 32
c. BP 110/70 mm Hg, Pulse 120 BPM, RR 32
d. BP 148/78 mm Hg, Pulse 112 BPM, RR 28
3. A client is at the emergency room with suspected spinal cord and head injuries has a Glasgow Coma scale of 15; blood pressure 133/84 mm Hg, pulse of 102 bpm, RR 19 and temperature of 98F (36.6C). What is the most important nursing intervention during the initial care of the client ?
a. Avoid moving the client
b. Keep the head of the bed elevated 30 degrees
c. Check the extremities for range of motion
d. Turn the client to the side to avoid aspiration
Spinal precautions include BED REST, NO NECK FLEXION WITH A PILLOW OR ROLL, NO THORACIC OR LUMBAR FLEXION WITH HOB ELEVATION/BED CONTROLS (REVERSE TRENDELENBURG IS
ACCEPTABLE). Rigid cervical collar or long spine board are used to prevent new or secondary spine injury if there is unstable vertebrae or ligament damage.
4. A client with acute ischemic stroke is ordered to receive alteplase. The client weighs 160.6 lbs. Based on standard alteplase administration for stroke, how many mL per hour will the nurse run bolus?
a. 386
b. 1
c. 3864
d. 65.7
5. A client receiving cyclosporine must be taught which of the following?
a. It’s alright to continue working at a daycare
b. Report signs of dark urine and yellowing of the skin
c. Nausea is an expected side effect
d. Bruising is an expected side effect.
Cyclosporine main side effect is Nephrotoxicity. (PAGE 302)
6. A client is admitted to the critical care unit with a subdural hematoma. The nurse is assessing the client’s GCS score. When assessing the client’s best motor response, which movement would receive the lowest score?
a. Abnormal extension
b. Decorticate posturing
c. Withdrawing from pain
d. Localizing Pain
MOTOR RESPONSE OBEYS COMMANDS – 6 LOCALIZES PAIN – 5
NORMAL FLEXION (WITHDRAWAL) – 4
ABNORMAL FLEXION (DECORTICATE POSTURING) – 3 EXTENSION (DECEBERATE) – 2
NONE – 1
7. The nurse is starting a peripheral intravenous catheter in the right hand of an unconscious patient. During the procedure the client reaches over with his left hand and tries to remove the noxious (anything adversely affecting client *PAIN) stimuli. How would the nurse document this response?
a. Decorticate posturing
b. Localization
c. Decerebrate posturing
d. Withdrawal
8. A client with increased intracranial pressure is admitted to the intensive care unit. On admission, the nurse determines the client’s Glasgow Coma Scale is 10. One hour later, the client’s score is
13. Which interpretation would the nurse make?
a. The client’s condition has improved
b. The client is ready for discharge
c. The client is comatose
d. The client’s condition is worsening
9. Prescribed: Heparin infusion at 30 mL/hr. The provided solution is 40,000 units heparin in 500 mL D5W. How many units/hour will the client receive?
a. 40 B. 267
C. 2400
D. 16.67
10. A client with a serious head injury has been admitted. The nurse knows that certain neurologic findings can indicate the prognosis for the client. Which finding denotes the most serious prognosis?
a. Decorticate posturing (3 on GCS)
b. GCS score of 12 (15 is perfect)
c. Decerebrate posturing (2 on GCS)
d. Absence of Babinski reflex (NORMAL)
11. A client received a bone marrow transplant for treatment of leukemia after completing chemotherapy and radiation. The client develops a severe generalized skin rash 10 days after the transplant. The nurse recognizes this reaction is an indication of which of the following? a. Donor T cells are attacking the client’s skin cells
b. Client will need treatment to prevent hyperacute rejection
c. Client’s antibodies are rejecting the donor bone marrow
d. Client is experiencing a delayed hypersensitivity reaction.
Tissues usually attacked in GVHD are the skin (maculopapular rash), eyes, intestinal system and GI tract. May begin 7 to 30 days after transplantation.
12. A client is started on immunosuppressant drugs after kidney transplantation and will be taking azathioprine as part of a drug regimen. The client asks the nurse why it is necessary to have a specimen for a complete blood count drawn at the beginning of the therapy and then periodically thereafter. The nurse explains that azathioprine can alter blood cells and tells the client that it is most critical to report which of the following?
a. Easy bruising
b. Fatigue
c. Constipation [Show Less]
