ATI CUSTOM: AH2- FA25- Exam 2
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Free ATI CUSTOM: AH2- FA25- Exam 2 Questions
A nurse is caring for a client with fever, cough, and chills. Which diagnostic tests does the nurse anticipate to confirm sepsis?
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Electrocardiogram (ECG) and magnetic resonance imaging (MRI)
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Complete blood count (CBC), blood cultures, and lactic acid
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Urinalysis, chest X-ray, and arterial blood gas
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Liver function tests and renal function tests
Explanation
A CBC, blood cultures, and lactic acid level are key diagnostic tests for confirming sepsis. The CBC evaluates for leukocytosis or leukopenia, both indicators of systemic infection. Blood cultures identify the causative organism, allowing targeted antibiotic therapy. Elevated lactic acid levels reflect tissue hypoperfusion and cellular hypoxia, hallmark signs of sepsis severity. These tests together confirm infection and guide timely, evidence-based management.
A nurse is caring for a client who has burns to approximately 50% of their body. Which of the following physiological changes related to the burns should the nurse anticipate? (Select all that apply.)
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Capillary leak
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Hypermagnesemia
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Decreased plasma volume
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Diuresis
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Loss of protein
Explanation
Major burns cause increased capillary permeability, allowing fluid, electrolytes, and proteins to leak from the intravascular space into interstitial tissues. This capillary leak results in edema, hypovolemia, and decreased perfusion.
C. Decreased plasma volume
Fluid shifts from the intravascular to interstitial spaces lead to reduced circulating plasma volume, contributing to hypotension and shock if not treated promptly with fluid resuscitation.
E. Loss of protein
Plasma proteins, especially albumin, leak out of damaged capillaries, reducing oncotic pressure and exacerbating fluid loss and edema. This loss contributes to decreased blood volume and poor tissue perfusion.
A nurse has received report on a client who has a basilar skull fracture. Which of the following findings should the nurse anticipate with this client?
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Chvostek's sign
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Pooling of blood and edema around the eyes
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Ability to recall how the injury occurred
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Bruising over the mastoid process
Explanation
Bruising over the mastoid process, known as Battle’s sign, is a hallmark indicator of a basilar skull fracture. This bruising occurs behind the ear due to blood leakage from a fracture in the temporal bone. It often appears several hours after injury and may be accompanied by raccoon eyes (periorbital ecchymosis) or cerebrospinal fluid (CSF) leakage from the nose or ears. These findings signal potential dural tears and risk for infection such as meningitis.
A nurse is teaching a client who has a complete spinal cord injury about bowel and bladder management. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
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"To achieve a bowel movement, daily digital stimulation will need to be done."
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"Do not drink fluids excessively as this may cause diarrhea."
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"You will need to learn how to do self-intermittent catheterization to drain your bladder."
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"It will be necessary to take a stool softener to keep you from becoming constipated."
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"Suprapubic catheterization might have to be done if you are unable to catheterize yourself."
Explanation
Clients with complete spinal cord injuries lose voluntary control of bowel function. Digital stimulation or suppositories at consistent times each day help trigger reflex defecation and establish a regular bowel program.
C. "You will need to learn how to do self-intermittent catheterization to drain your bladder."
Neurogenic bladder is common after spinal cord injury. Intermittent catheterization every 4–6 hours helps prevent bladder overdistention, urinary retention, and infection while maintaining bladder health.
D. "It will be necessary to take a stool softener to keep you from becoming constipated."
Loss of bowel motility and decreased activity predispose clients to constipation. Stool softeners and adequate fiber and fluid intake help maintain bowel regularity and prevent impaction.
E. "Suprapubic catheterization might have to be done if you are unable to catheterize yourself."
If the client cannot safely or effectively perform self-catheterization, a suprapubic catheter provides a long-term alternative for bladder drainage and reduces the risk of urethral trauma and infection.
A nurse is performing a primary survey on a newly admitted client to the emergency room. Using the ABCDE assessment, which of the following areas are assessed under the "C" category?
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Mouth, larynx, and bronchi
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Heart and blood vessels
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Response to voice and pain
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Oxygen saturation and respiratory rate
Explanation
In the ABCDE primary survey, "C" stands for Circulation. During this stage, the nurse assesses the heart and blood vessels to determine the adequacy of perfusion and identify any life-threatening bleeding or circulatory compromise. Assessment includes checking pulse (rate, rhythm, quality), blood pressure, skin color and temperature, capillary refill, and looking for signs of hemorrhage or shock. The goal is to ensure effective cardiac output and tissue perfusion.
A nurse is caring for a client who has had a traumatic fall. Which of the following interventions should the nurse implement first?
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Insert an indwelling urinary catheter to monitor urine output
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Prepare for a STAT non-contrast CT scan
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Perform a thorough health history
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Administer acetaminophen by mouth for pain control
Explanation
After a traumatic fall, the priority is to assess for potential life-threatening injuries, especially head, neck, or spinal trauma. A STAT non-contrast CT scan is the first intervention to rapidly evaluate internal injuries, intracranial bleeding, or fractures. Early imaging allows prompt diagnosis and treatment, preventing secondary complications such as increased intracranial pressure or paralysis. Safety and stabilization always take precedence over comfort measures or routine assessments.
A client with a spinal cord injury at the T1 level complains of a severe headache and an “anxious feeling.” Which is the most appropriate initial reaction by the nurse?
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Place the client in Trendelenburg position
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Administer anxiolytic medication
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Assess for a full bladder
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Assess pupillary response
Explanation
A severe headache and anxiety in a client with a spinal cord injury at or above T6 are classic signs of autonomic dysreflexia, a life-threatening emergency caused by excessive sympathetic discharge due to a noxious stimulus below the level of injury. The most common cause is a distended bladder. The nurse should immediately check for bladder distension, ensure catheter patency, or perform straight catheterization if needed to relieve the trigger and prevent complications such as stroke or seizures.
A nurse is caring for a client with anaphylaxis. Which of the following are appropriate nursing interventions to decrease risk for deterioration? (Select All that Apply.)
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Offer the client a glass of water
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Administer epinephrine as ordered
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Administer a sedative medication
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Monitor vital signs frequently
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Administer a medication to reverse bronchoconstriction
Explanation
Epinephrine is the first-line treatment for anaphylaxis. It rapidly reverses airway obstruction by causing bronchodilation, reduces vasodilation to improve blood pressure, and decreases mucosal edema. Administering epinephrine immediately prevents further deterioration, cardiac arrest, or respiratory failure. It acts on both alpha and beta receptors to stabilize cardiovascular and respiratory function during the crisis.
D. Monitor vital signs frequently
Frequent monitoring allows the nurse to assess response to treatment and detect early signs of worsening shock or respiratory distress. Continuous evaluation of heart rate, blood pressure, oxygen saturation, and respiratory rate ensures that the nurse can intervene quickly if hypotension, tachycardia, or hypoxia develop during anaphylactic progression or recovery.
E. Administer a medication to reverse bronchoconstriction
Medications such as beta-agonists (e.g., albuterol) are used to relieve bronchospasm that can persist even after epinephrine. These drugs improve airflow and oxygenation by relaxing airway smooth muscles, preventing hypoxia and respiratory failure. Administering bronchodilators supports respiratory stability and enhances the overall effect of epinephrine.
A nurse is caring for a client who was involved in a motor vehicle accident. The client is alert and oriented and reports a loss of consciousness immediately after the accident. Which of the following additional manifestations should the nurse assess the client for? (Select All that Apply.)
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Pupillary dilation
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Persistent headache
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Presence of hand tremors
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Difficulty waking
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Foot drop
Explanation
Unequal or dilated pupils may indicate increased intracranial pressure (ICP) or brain herniation from bleeding or swelling after head trauma. This is a neurological emergency that requires immediate assessment and provider notification.
B. Persistent headache
A continuous or worsening headache following a head injury suggests concussion or intracranial bleeding. This is a key symptom of post-concussion syndrome or a developing hematoma and must be closely monitored for changes in severity or frequency.
D. Difficulty waking
Difficulty arousing the client indicates decreasing level of consciousness and potential progression of intracranial pressure or hemorrhage. It is a critical early sign of neurologic deterioration requiring urgent evaluation.
A nurse is caring for a client with an electrical burn. The client states that since the wound on the skin is small, the burn must not be too bad. Which of the following is the best response by the nurse?
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Electrical burns usually cause much more skin damage than what can be seen on your skin.
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Electrical burns typically are minor.
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Electrical burns can have small amounts of skin damage, but more extensive damage beneath the skin.
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Electrical burns commonly cause reddened/purplish skin without blistering.
Explanation
Electrical burns often appear deceptively minor on the surface but can cause deep internal tissue injury along the current’s pathway. The electrical current travels through muscles, nerves, and blood vessels, generating heat that leads to severe internal damage, cardiac dysrhythmias, and possible organ involvement. The visible skin wound represents only the entry and exit points of the current, not the true extent of injury.
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