Exam (elaborations)
ATI 265 MED SURG UPDATED EXAM (LATEST 2024/2025) 100% GUARANTEED PASS
- Course
- ATI 265 MEd Surg
- Institution
- Galen College Of Nursing
ATI 265 MED SURG UPDATED EXAM (LATEST 2024/2025) 100% GUARANTEED PASS
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ATI 265 MED SURG UPDATED EXAM (LATEST2024/2025) 100% GUARANTEED PASS
A client has a new tracheostomy, on a MV with the settings: rate of 12, TV 800 Flo2 80% and
PEEP of 5. Which assessment requires immediate action?
- Constant non productive cough
- Rhonchi in upper lobes
- Blood tinged sputum
- Dry mucous membranes
The nurse palpates the posterior chest while the client says 99 and notes absent fremitus.
Which action should the nurse take next?
- Review the chest xray report for evidence of pneumonia
- Encourage the client to turn, cough and deep breathe
- Auscultate anterior and posterior breath sounds bilaterally
- Palpate the anterior chest and observe the barrel chest
The nurse is caring for a client with a PE also has RSHF. which clinical findings requires
immediate follow up?
- 2 plus dep edema to bilateral ext.
- Urinary output of 25 ml/hr
- Heart rate of 115 beats/min
- Respiratory rate of 30
The nurse has been made aware of the ABG results of 4 clients. Which result is most
important?
- Ph 7.31 pa 02 81 pacos 50 02 sat 94
- Ph 7.46 pao2 90 paco2 32 02 98%
- Ph 7.35 pao2 85, paco2 45 o2 95%
- Ph 7.34 pao2 82 paco2 40 o2 97%
The nurse monitors a client after a chest tube insertion for a hemopneumothorax. Which of the
assessments requires immediate follow up?
- Sub q emphysema at insertion site
- Platelets 151000
- Tidaling in the water seal chamber
- 400 ml of blood in collection chamber
When assessing a client who has just arrived afer an auto accident, the er notes hr 125 and
absent breath sounds over right lung. Which action is priority
, - Send client for a state ct scan
- Insertion of chest tube with drainage system
- Administer inhaled bronchodilator
- Prepare for oral intubation with mv
A nurse assesses a client who is experiencing an acid balance imbalance. Ph 7.33, pa 02 88
pacos 38 and hco3 17. Which assessment would the nurse perform first?
- Level or orientation
- Musculoskeletal strength
- Cardiac rate and rhythm
- Skin and mucous membranes
A client admitted to er says he was struck in chest with bat. Which of the assessments requires
immediate follow up?
- Hr of 112
- Decreased tactile fremitus
- Paradoxical chest movement
- Rr 25 o2 sat of 91%
Which client should nurse assess first?
- A client with three fractured ribs request pain meds
- A client with hyperparathyroidism has abdominal pain and nausea
- A client with hypothyroidism reports last bowel movement ws three days ago
- A client admitted with addison's disease complains of dizziness when standing
The nurse auscultates the lungs of a client on mv and hears vesicular breath sounds throughout
the right side but decreased sounds on the left side of chest. Which action should the nurse take
next?
- Turn the client to right side
- Hyperoxygenate
- Assess placement of et tube at lip
- Elevate the head of the bed
A client is admitted from a mva trauma with difficulty breathing. The nurse assesses the clients
color lung sounds and pulse ox is 90. Which is priority intervention.
- Assess an abg
- Administer 2 mg morphine
- Call for chest xray
- Initiate ns ivf
Which client should nurse assess first?
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