ATI ADVANCED ADULT MED SURG EXAM GUIDE
A nurse is reviewing the health records of clients. Which client is
at least risk fordeveloping acute
... [Show More] respiratory distress syndrome
(ARDS)?-
(a) A client who experienced a near-drowning incident in freshwater x
(b) A client following coronary artery bypass graft surgery x
(c) A client who has a hemoglobin of 10.1 mg/dLpost 1-unit PRBC
(d) A client who is experiencing acute pancreatitis and vomitingx
A client presented to the ED after receiving second and third degree
burns from a kitchen grease spill. The tops of both thighs, the groin
area, and lower abdomen were the areas of injury. About three hours
after the injury, the client begins to decompensate and is being
prepped for intubation. Regarding the change in the client's status,
which explanation by the nurse is correct when educating the client's
family?
(a)Even aburn as little as 25% of thebody can causea systemic
response, requiringemergency management"
(b)Theclient is complaining of servepain and will beintubated tosafety
given painmedication and seductive
(c)The client is experiencing a paralytic ileum and requires intubation to
prevent furtherdamage
(d)Fluidshift in thebody immediately causeanincreased cardiac output
and increasedtissue profusion which can negatively affect the healing
process
A nurse is caring fora client who is in the non-progressive
(compensatory) stage ofhypervolemic shock. Which finding should
the nurse anticipate? ***
(a)Multi-organ Dysfunction Syndromeand seizures
(b)Increasethirst reflexand moderatevasoconstriction
(c)pH 7.5 and potassium level of 3.0 mEq/L –hypokalemia occurs
(d)Decrease in MAP by 20 points from baseline
A nurse is reviewing the health records of clients. Which client is at
greatest risk fordeveloping Acute Respiratory Distress Syndrome
(ARDS) and Multiple Organ Dysfunction Syndrome (MODS)?
(a) A client who experienced neurogenic shock
(b) A client following anaphylactic
shock (c) A client who is experiencing
septic shock
(d) A client who is experiencing obstructiveshock
When caring fora patient who has septic shock, which assessment
finding is mostimportant for the nurse to report to the care
provider?
(a) BP 92/56
(b) Skin cool and clammy- means progression
(c) Apicalpulse118 beats/min
(d)Arterial oxygen saturation 91%
Calculate the mean arterial pressure (MAP) in mmHg fora patient
with a bloodpressure of 84/46mmHg. (Record answer to the
nearest whole number)
MAP = SBP + 2 (DBP)/
3
84+2(46)/3=59
The emergency department nurse is assessing a client who has
sustained a bluntinjury to the chest wall. Which finding would
indicate the presence of pneumothorax in this client?
(a) A low respiratory
rate (b) Diminished
breathsounds
(c) Thepresence of abarrel chest-copd
(d) A sucking sound at the siteof injury-open chest
The nurse is assessing the respiratory status of aclient who has
suffered afracturedrib.The nurse should expect to note which
finding?
(a) Slow deep respirations
(b)Rapiddeep respiration
(c) Paradoxical respirations
(d) Pain, especially withinspiration
A client with a chest injury has suffered a flail chest. The nurse
assesses the clientfor which most distinctive sign of flail chest?
(a) Cyanosis
(b)Hypotension
(c) Paradoxical chest movement-hall mark
(d)Dyspnea,especially onexhalation
A client has been admitted with chest trauma after a motor vehicle
crash and has undergone subsequent intubation. The nurse checks
the client when the high- pressure alarm on the ventilator sounds
and notes that the client has an absence ofbreath sounds in the
right upper lobe of the lung. The nurse immediately assesses for
other signs of which condition?
(a) Right pneumothorax
(b) Pulmonary embolism
(c) Displaced endotracheal tube
(d) Acuterespiratory distress syndrome
A burn patient is brought into the emergency department with the
following burns:half of the front torso(9), entire left arm (9), front of
left le (9)g. The nurse should record the TBSA burns as.
(a)27% TBSA
(b)35% TBSA
(c)20%TBSA
(d)40% TBSA
The client, who is one-day postoperative following chest surgery is
having difficultybreathing, has bilateral rales, and is confused and
restless. Which intervention should the nurse implement first?
(a) Assess theclient pulseoximeter
reading(b) Notify the rapid response
team
(c) Placetheclient intheTrendelenburg position
(d) Check theclient’s surgicaldressing [Show Less]