ATI RN MED SURG 2 EXAM WITH NGN
COMPLETE WITH EXPLAINED
ANSWERS
A nurse is implementing the ventilator care bundle for a client who is receiving
mechanical ventilation. Which of the following should the nurse expect to find
in the bundle?
A. Instructions on how to change ventilator settings
B. Instructions on mouth care
C. Instructions to suction the client’s tracheostomy every 2 hr
D. Instructions to place the client in a supine position
RATIONALES
A. Instructions on how to change ventilator settings:
Ventilator settings are typically adjusted by respiratory therapists or healthcare providers
based on the client's respiratory status. While nurses may be involved in monitoring,
changing ventilator settings is not part of the routine nursing care bundle.
B. Instructions on mouth care
Mouth care is an important component of the ventilator care bundle to prevent ventilator-
associated pneumonia (VAP). Proper oral hygiene, including regular mouth care, can help
reduce the risk of infection.
C. Instructions to suction the client’s tracheostomy every 2 hr:
Suctioning frequency is determined based on the client's needs and is not a fixed component
of the ventilator care bundle. Suctioning is performed as necessary to maintain airway
patency.
D. Instructions to place the client in a supine position:
The positioning of the client may be individualized based on the clinical condition.
However, placing the client in a supine position is not a fixed component of the ventilator
care bundle. The emphasis is on practices that prevent complications associated with
mechanical ventilation.
A nurse is caring for a client following a total laryngectomy. Which of the
following is the priority observation in the client’s care?
A. integrity of the dressing
B. Need for suctioning
C. Patency of the intravenous line
D. Level of pain
RATIONALES
,A. Integrity of the dressing:
Dressing integrity is important for wound care, but it is not the top priority when
considering the client's immediate postoperative needs.
B. Need for suctioning
Maintaining a patent airway is crucial after a total laryngectomy. The absence of a larynx
removes the client's ability to breathe through the nose and mouth, so maintaining a clear
airway is a top priority. Suctioning may be necessary to remove secretions and maintain
airway patency.
C. Patency of the intravenous line:
Intravenous line patency is important for fluid and medication administration, but it is not
the priority when compared to maintaining a clear airway.
D. Level of pain:
Pain management is important for the client's comfort, but it is not the immediate priority
compared to ensuring a patent airway following a total laryngectomy.
A nurse in a clinic is caring for a client who has a new diagnosis of systemic
lupus erythematosus (SLE). Physical Examination.
Client's first visit: The client presents with a rash and cutaneous plaques on the
scalp, face, and neck.
Areas of hyperpigmentation are also noted.
A butterfly rash is present on the cheeks.
The client reports progressive fatigue, despite increasing rest periods.
The client reports joint tenderness.
+1 edema is noted.
The client denies chest pain or discomfort.
S1 S2 is noted on auscultation.
No pericardial friction rub or murmurs are noted.
The chest is clear on auscultation.
The client denies shortness of breath, cough, or congestion.
Bowel sounds are present in all four quadrants.
The client denies any gastrointestinal issues.
The client reports urinating with no difficulty.
Weight: 185.
Diagnostic Results: Antinuclear antibody (ANA): Positive (Negative).
Erythrocyte sedimentation rate (ESR): 38 mm/hr (up to 20 mm/hr).
Hemoglobin: 10 g/dL (12 to 18 g/dL). Hematocrit: 35% (37% to 52%). WBC
,count: 10,500/mm (5,000 to 10,000/mm). Platelet count: 100,000/mm
(150,000 to 400,000/mm). Glucose: 285.
Weight: 220.
Echocardiogram: The position, size, and movement of the cardiac valves and
heart muscle are all as expected.
The directional flow of blood within the heart chambers is within the expected
reference range.
Bone mineral density: T Score: 0.9 (T score less than 1 standard deviation
below normal). Laboratory tests: Urinalysis to check for proteinuria.
Echocardiogram to assess heart function.
Screening for osteoporosis with baseline bone mineral density test.
Begin medication therapy with Prednisone and NSAID.
Will add immunosuppressive therapy following verification of diagnostics.
Client's second visit: The client returns to the clinic for a medication check and
to discuss the new laboratory findings.
Drag words from the choices below to fill in each blank in the following
sentence.
Based on the client's prescribed medications, the nurse should assess the client
for developing Target 1? and Target 2? Word Choices:
A. Hypoglycemia.
B. Weight loss.
C. Weight gain.
D. Hyperglycemia.
RATIONALES
Choice A rationale:
Hypoglycemia is a condition characterized by low blood sugar levels. However, the client is
on Prednisone and NSAIDs, which do not typically cause hypoglycemia. Therefore, it’s
unlikely that the client would develop this condition as a side effect of these medications.
Choice B rationale:
Weight loss could occur in some individuals taking Prednisone due to potential side effects
like loss of appetite or stomach upset. However, it’s more common for individuals on
Prednisone to experience weight gain due to increased appetite.
Choice C rationale:
Weight gain is a common side effect of Prednisone. This medication can cause increased
appetite leading to weight gain. It can also cause fluid retention and redistribution of fat,
particularly in the face, back of the neck, and abdomen.
Choice D rationale:
Hyperglycemia, or high blood sugar, is a potential side effect of Prednisone. This medication
can cause an increase in blood sugar levels, which if persistently high, can lead to diabetes.
Regular monitoring of blood glucose levels is recommended for clients on this medication.
, A charge nurse allows two nurses who are arguing about who gets to go to
lunch first to go together. The charge nurse agrees to take care of the nurses
clients while they are at lunch. The charge nurse is demonstrating which of the
following types of conflict management?
A. Cooperating
B. Avoiding
C. Compromising
D. Competing
RATIONALES
A. Cooperating:
Cooperating, also known as collaborating or accommodating, involves working together to
find a solution that satisfies the concerns of all parties involved. It emphasizes open
communication, empathy, and a win-win solution. In this scenario, the charge nurse is
cooperating by allowing both nurses to go to lunch together and taking care of their clients,
ensuring that both parties' needs are considered.
B. Avoiding:
Avoiding is a conflict management style where individuals may ignore or avoid the conflict
altogether. This can be a temporary solution, but it doesn't address the underlying issues. In
this scenario, the charge nurse is not avoiding the conflict but actively addressing it by
allowing the nurses to go to lunch together.
C. Compromising:
Compromising involves finding a middle ground or a solution that partially satisfies each
party's concerns. It often requires both parties to give up something to reach an agreement.
The charge nurse, in this scenario, is not necessarily compromising, as both nurses are
allowed to go to lunch together without requiring them to give up something.
D. Competing:
Competing involves pursuing one's own concerns at the expense of others. It is a win-lose
approach to conflict resolution. The charge nurse is not demonstrating a competitive
approach in this scenario, as both nurses are accommodated to go to lunch together without
one person's needs being prioritized over the other.
A client is admitted to the emergency room with a respiratory rate of 7/min.
Arterial blood gases (ABG) reveal the following values. Which of the following
is an appropriate analysis of the ABGs?
pH 7.22
PaCO: 68 mm Hg
Base excess-2
Pa0: 78 mm Hg
Saturation 80%
