ATI CUSTOM: AH2- FA25- Exam 2
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Free ATI CUSTOM: AH2- FA25- Exam 2 Questions
1. A nurse is caring for a client with fever, cough, and chills. Which diagnostic tests does the nurse anticipate to confirm sepsis?
- Electrocardiogram (ECG) and magnetic resonance imaging (MRI)
- Complete blood count (CBC), blood cultures, and lactic acid
- Urinalysis, chest X-ray, and arterial blood gas
- Liver function tests and renal function tests
Explanation
B. Complete blood count (CBC), blood cultures, and lactic acid
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 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.
2. 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.)
- "To achieve a bowel movement, daily digital stimulation will need to be done."
- "Do not drink fluids excessively as this may cause diarrhea."
- "You will need to learn how to do self-intermittent catheterization to drain your bladder."
- "It will be necessary to take a stool softener to keep you from becoming constipated."
- "Suprapubic catheterization might have to be done if you are unable to catheterize yourself."
Explanation
A. "To achieve a bowel movement, daily digital stimulation will need to be done."
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.
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.
3. A nurse is reinforcing teaching to a group of nursing students about causes of traumatic brain injuries (TBIs). Which of the following should the nurse include in the teaching? (Select All that Apply.)
- Falls
- Violence
- Sports-related injuries
- Working as a firefighter
- Working in a factory
Explanation
A. Falls
Falls are the most common cause of traumatic brain injuries, especially in older adults and young children. Head impact from losing balance or slipping can cause concussions, contusions, or intracranial bleeding. Prevention includes environmental safety and use of assistive devices.
B. Violence
Acts of violence such as assaults, gunshot wounds, and domestic abuse are major contributors to TBIs. Penetrating injuries or blunt force trauma can lead to severe brain damage or death, making this a significant preventable cause.
C. Sports-related injuries
Contact sports (football, boxing, hockey) and recreational activities can cause repetitive concussions or acute TBIs. Helmets and proper safety equipment help reduce risk, but athletes remain at high exposure to impact injuries.
Falls are the most common cause of traumatic brain injuries, especially in older adults and young children. Head impact from losing balance or slipping can cause concussions, contusions, or intracranial bleeding. Prevention includes environmental safety and use of assistive devices.
B. Violence
Acts of violence such as assaults, gunshot wounds, and domestic abuse are major contributors to TBIs. Penetrating injuries or blunt force trauma can lead to severe brain damage or death, making this a significant preventable cause.
C. Sports-related injuries
Contact sports (football, boxing, hockey) and recreational activities can cause repetitive concussions or acute TBIs. Helmets and proper safety equipment help reduce risk, but athletes remain at high exposure to impact injuries.
4. When planning immediate care for a client with moderate burns, what interventions should the nurse anticipate providing? (Select all that apply.)
- Use of topical antibiotics on the wounds
- Application of ice packs to the burned areas
- Mechanical ventilation for severe respiratory deterioration
- Laboratory studies to determine fluid-volume status
- Administration of tetanus immunization
- Immediate IV access with Lactated Ringer’s solution
Explanation
A. Use of topical antibiotics on the wounds
Topical antimicrobials such as silver sulfadiazine or bacitracin are applied to reduce the risk of infection. The skin’s protective barrier is lost in burn injuries, so infection prevention is a top priority in initial wound care.
D. Laboratory studies to determine fluid-volume status
Burns cause massive fluid shifts and electrolyte imbalances. Labs such as hematocrit, electrolytes, and BUN/creatinine help guide fluid resuscitation and monitor the client’s response to treatment.
E. Administration of tetanus immunization
Burn wounds create an entry point for Clostridium tetani, so tetanus prophylaxis is part of standard burn management, especially if immunization status is uncertain or outdated.
F. Immediate IV access with Lactated Ringer’s solution
Lactated Ringer’s is the preferred fluid for burn resuscitation because it closely resembles extracellular fluid composition. Early IV access ensures rapid replacement of fluids to maintain perfusion and prevent hypovolemic shock.
Topical antimicrobials such as silver sulfadiazine or bacitracin are applied to reduce the risk of infection. The skin’s protective barrier is lost in burn injuries, so infection prevention is a top priority in initial wound care.
D. Laboratory studies to determine fluid-volume status
Burns cause massive fluid shifts and electrolyte imbalances. Labs such as hematocrit, electrolytes, and BUN/creatinine help guide fluid resuscitation and monitor the client’s response to treatment.
E. Administration of tetanus immunization
Burn wounds create an entry point for Clostridium tetani, so tetanus prophylaxis is part of standard burn management, especially if immunization status is uncertain or outdated.
F. Immediate IV access with Lactated Ringer’s solution
Lactated Ringer’s is the preferred fluid for burn resuscitation because it closely resembles extracellular fluid composition. Early IV access ensures rapid replacement of fluids to maintain perfusion and prevent hypovolemic shock.
5. 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?
- Mouth, larynx, and bronchi
- Heart and blood vessels
- Response to voice and pain
- Oxygen saturation and respiratory rate
Explanation
B. Heart and blood vessels
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.
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.
6. A nurse is caring for a client who has increased intracranial pressure (ICP) and has a worsening neurologic condition. Which of the following cues should the nurse recognize as a worsening condition? (Select All that Apply.)
- Respiratory rate of 12/min
- Changes to pupil size and shape
- Swelling of the optic nerve
- Blood pressure of 108/74 mm Hg
- Decreasing Glasgow Coma scores
Explanation
B. Changes to pupil size and shape
Alterations in pupil size, shape, or reactivity indicate pressure on cranial nerve III (oculomotor nerve) due to increased intracranial pressure. Unequal or fixed pupils suggest herniation or further compression of brain structures, requiring immediate intervention.
C. Swelling of the optic nerve
Papilledema, or optic nerve swelling, results from sustained ICP that impedes venous drainage in the optic nerve sheath. It is a key indicator of worsening intracranial pressure and may cause visual disturbances or blindness if not treated promptly.
E. Decreasing Glasgow Coma scores
A declining Glasgow Coma Scale (GCS) score reflects deteriorating neurologic function, signaling increased brain compression or decreased cerebral perfusion. Even a one-point drop is clinically significant and warrants immediate reassessment and provider notification.
Alterations in pupil size, shape, or reactivity indicate pressure on cranial nerve III (oculomotor nerve) due to increased intracranial pressure. Unequal or fixed pupils suggest herniation or further compression of brain structures, requiring immediate intervention.
C. Swelling of the optic nerve
Papilledema, or optic nerve swelling, results from sustained ICP that impedes venous drainage in the optic nerve sheath. It is a key indicator of worsening intracranial pressure and may cause visual disturbances or blindness if not treated promptly.
E. Decreasing Glasgow Coma scores
A declining Glasgow Coma Scale (GCS) score reflects deteriorating neurologic function, signaling increased brain compression or decreased cerebral perfusion. Even a one-point drop is clinically significant and warrants immediate reassessment and provider notification.
7. A nurse is caring for a client in the intensive care unit who was admitted with severe head trauma and cerebral edema. The client opens their eyes spontaneously, is oriented, and obeys commands. Which of the following findings indicate the client is experiencing a decline in their condition when the patient is reassessed? (Select all that apply.)
- Client responds to name
- Eyes open to painful stimuli
- Client states day of the week
- Client is confused
- Client mumbles inappropriate words
- Eyes do not open to name
Explanation
B. Eyes open to painful stimuli
Initially, the client opened their eyes spontaneously—a Glasgow Coma Scale (GCS) score of 4 for eye response. Opening eyes only to pain indicates a decrease to a GCS of 2, showing neurologic deterioration and decreased responsiveness.
D. Client is confused
The client was initially oriented (GCS verbal score of 5). Confusion represents a drop to a verbal score of 4, meaning cognitive decline and worsening cerebral function due to increasing intracranial pressure.
E. Client mumbles inappropriate words
Inappropriate or incomprehensible speech indicates further decline in the verbal component of the GCS. This suggests disruption of higher brain centers and possible progression of cerebral edema or increased ICP.
F. Eyes do not open to name
Failure to respond to verbal stimulation indicates decreasing level of consciousness. This loss of responsiveness is consistent with worsening neurological status and must be reported immediately.
Initially, the client opened their eyes spontaneously—a Glasgow Coma Scale (GCS) score of 4 for eye response. Opening eyes only to pain indicates a decrease to a GCS of 2, showing neurologic deterioration and decreased responsiveness.
D. Client is confused
The client was initially oriented (GCS verbal score of 5). Confusion represents a drop to a verbal score of 4, meaning cognitive decline and worsening cerebral function due to increasing intracranial pressure.
E. Client mumbles inappropriate words
Inappropriate or incomprehensible speech indicates further decline in the verbal component of the GCS. This suggests disruption of higher brain centers and possible progression of cerebral edema or increased ICP.
F. Eyes do not open to name
Failure to respond to verbal stimulation indicates decreasing level of consciousness. This loss of responsiveness is consistent with worsening neurological status and must be reported immediately.
8. A nurse is teaching a group of nursing students about brain herniation. Which of the following interventions should the nurse include as a possible treatment for brain herniation?
- Reduce the temperature in the room
- Lower blood pressure
- Hyperventilate the client
- Decrease sedation
Explanation
C. Hyperventilate the client
Hyperventilation is used temporarily in the management of brain herniation to reduce intracranial pressure (ICP). By lowering the arterial carbon dioxide (PaCO₂) level, cerebral vasoconstriction occurs, which decreases cerebral blood flow and volume, thereby lowering ICP. This is an emergency measure used only short-term while definitive treatment, such as surgical decompression or osmotic therapy (e.g., mannitol), is initiated.
Hyperventilation is used temporarily in the management of brain herniation to reduce intracranial pressure (ICP). By lowering the arterial carbon dioxide (PaCO₂) level, cerebral vasoconstriction occurs, which decreases cerebral blood flow and volume, thereby lowering ICP. This is an emergency measure used only short-term while definitive treatment, such as surgical decompression or osmotic therapy (e.g., mannitol), is initiated.
9. 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.)
- Offer the client a glass of water
- Administer epinephrine as ordered
- Administer a sedative medication
- Monitor vital signs frequently
- Administer a medication to reverse bronchoconstriction
Explanation
B. Administer epinephrine as ordered
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.
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.
10. Nurse's Notes
Postoperative day #1
0700
Client is alert and oriented x 3. Lung sounds diminished in the bases, no adventitious sounds noted. Oxygen saturation is 89% on room air. Denies shortness of breath. Bowel sounds active × 4, denies having a bowel movement since surgery. Client rates pain as a 10 on a 0-10 pain scale and reports morphine 5 mg IVP that was administered 30 minutes ago is not working. Left leg splint dry with old drainage noted. Left foot cool to touch with absent posterior tibial and dorsalis pedis pulses. Capillary refill to left foot toes greater than 2 seconds. Cyanosis noted to left leg. Client reports tingling to left foot toes. 2+ edema noted to left leg/foot.
Orders
Postoperative day #1
Vital signs every 4 hours
Obtain blood glucose before meals and at bedtime
Diet as tolerated
Oxygen per nasal cannula to maintain oxygen saturation above 95%
Physical therapy to evaluate
Morphine sulfate 2-10 mg every 2-4 hours prn pain
Humalog insulin subcutaneous (SQ) sliding scale for blood glucose
Blood glucose less than 80 notify the health care provider
Blood glucose 80 mg/dL to 150 mg/dL = 10 units
Blood glucose 151 mg/dL to 200 mg/dL = 15 units
Blood glucose 201 mg/dL to 250 mg/dL = 20 units
Blood glucose 251 mg/dL to 300 mg/dL = 25 units
Blood glucose 301 mg/dL to 350 mg/dL = 30 units
Blood glucose 351 mg/dL to 400 mg/dL = 35 units
Greater than 401 mg/dL notify the health care provider
Vital Signs
Postoperative day #1
0700
Temperature 37.5°C (99.5°F)
Pulse rate: 94 beats/min
Respiratory rate: 24 breaths/min
Blood pressure: 140/85 mmHg
Oxygen saturation: 95% on room air
Which intervention should the nurse anticipate the healthcare provider prescribing? Select all that apply.
Postoperative day #1
0700
Client is alert and oriented x 3. Lung sounds diminished in the bases, no adventitious sounds noted. Oxygen saturation is 89% on room air. Denies shortness of breath. Bowel sounds active × 4, denies having a bowel movement since surgery. Client rates pain as a 10 on a 0-10 pain scale and reports morphine 5 mg IVP that was administered 30 minutes ago is not working. Left leg splint dry with old drainage noted. Left foot cool to touch with absent posterior tibial and dorsalis pedis pulses. Capillary refill to left foot toes greater than 2 seconds. Cyanosis noted to left leg. Client reports tingling to left foot toes. 2+ edema noted to left leg/foot.
Orders
Postoperative day #1
Vital signs every 4 hours
Obtain blood glucose before meals and at bedtime
Diet as tolerated
Oxygen per nasal cannula to maintain oxygen saturation above 95%
Physical therapy to evaluate
Morphine sulfate 2-10 mg every 2-4 hours prn pain
Humalog insulin subcutaneous (SQ) sliding scale for blood glucose
Blood glucose less than 80 notify the health care provider
Blood glucose 80 mg/dL to 150 mg/dL = 10 units
Blood glucose 151 mg/dL to 200 mg/dL = 15 units
Blood glucose 201 mg/dL to 250 mg/dL = 20 units
Blood glucose 251 mg/dL to 300 mg/dL = 25 units
Blood glucose 301 mg/dL to 350 mg/dL = 30 units
Blood glucose 351 mg/dL to 400 mg/dL = 35 units
Greater than 401 mg/dL notify the health care provider
Vital Signs
Postoperative day #1
0700
Temperature 37.5°C (99.5°F)
Pulse rate: 94 beats/min
Respiratory rate: 24 breaths/min
Blood pressure: 140/85 mmHg
Oxygen saturation: 95% on room air
Which intervention should the nurse anticipate the healthcare provider prescribing? Select all that apply.
- Check blood glucose
- Obtain blood pressure
- Prepare for fasciotomy
- Apply elastic anti-embolism stockings
- Ambulate patient
- Elevate left leg
- Perform neurovascular assessment
- Remove leg splint
Explanation
C. Prepare for fasciotomy
The client’s findings—cool, cyanotic left foot with absent dorsalis pedis and posterior tibial pulses, delayed capillary refill, and tingling—indicate compartment syndrome, a surgical emergency. A fasciotomy is required to relieve pressure and restore perfusion, preventing irreversible ischemia and potential limb loss. Immediate preparation for fasciotomy aligns with emergent treatment to preserve tissue viability.
G. Perform neurovascular assessment
Performing frequent neurovascular checks (color, temperature, pulses, sensation, capillary refill, and movement) is vital for monitoring progression of compromised circulation. These assessments provide critical data to determine worsening ischemia or nerve compression, guiding timely intervention and communication with the healthcare provider.
The client’s findings—cool, cyanotic left foot with absent dorsalis pedis and posterior tibial pulses, delayed capillary refill, and tingling—indicate compartment syndrome, a surgical emergency. A fasciotomy is required to relieve pressure and restore perfusion, preventing irreversible ischemia and potential limb loss. Immediate preparation for fasciotomy aligns with emergent treatment to preserve tissue viability.
G. Perform neurovascular assessment
Performing frequent neurovascular checks (color, temperature, pulses, sensation, capillary refill, and movement) is vital for monitoring progression of compromised circulation. These assessments provide critical data to determine worsening ischemia or nerve compression, guiding timely intervention and communication with the healthcare provider.
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