ATI MEDSURG 2 NUR 265/DETAILED
ANSWER KEY NEURO-SHOCK & BURNS
PRACTICE GRADED A+
The nurse is caring for a client who has a liver transplant 48 hours ago. It is a priority for the
nurse to notify the PHCP if the client has
- An increasing bilirubin level
- Scant amounts of serosanguinous drainage from the incision
- A urine output that has decreased from 65 to 45mL/ Hr since surgery
- An increase in BP from 115/68 to 122/74 - ANSWER -An increasing bilirubin level
The nurse is caring for a client who had a lung transplant 10 days ago. It is a priority for the
nurse to notify the PHCP if the client has
- Only used the incentive spirometer once since last evening
- Developed sputum that is yellow-tinged
- A pain rating of 7/10 when taking a deep-breath
- Refused high- frequency chest wall oscillation for the past 24 hrs. - ANSWER -Developed
sputum that is yellow-tinged
The nurse is caring for a client who had a kidney transplant 2 week ago. Which findings from the
box below should the nurse correlate to possible organ rejection?
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,1. Blood pressure of 116/66
2. Serum creatinine lvl of 2.5
3. Urinalysis is positive for protein
4. Serum potassium level of 5.8
5. Blood urea nitrogen (BUN) levl of 30. - ANSWER -2. Serum creatinine lvl of 2.5
4. Serum potassium level of 5.8
5. Blood urea nitrogen (BUN) levl of 30.
The nurse working in the PHCP office has just administered a routine immunization to a client.
The client is asked to wait in the waiting room for the next 15 minutes. five minutes later, the
client develops swlling of the eyes and reports feeling anxious, SOB, and dizzy. Which of the
following actions should the nurse take first?
- Elevate the client's feet and legs
- Perform a respiratory assessment
- Prepare tp administer diphenhydramine
- Obtain a full set of vital signs. - ANSWER -Perform a respiratory assessment
The nurse working in the emergency department (ED) is admitting a client who presents with
stridor, dyspnea, and bronchospasm after being stung by a bee. After notifying the ED health
care provider, which of the following action should the nurse take next?
-Administer an Albuterol nebulizer treatment.
-Initiate oxygen via a nonrebreather mask.
-Remove the bee sting from the site of the sting.
-Prepare to administer a corticosteroid. - ANSWER -Initiate oxygen via a nonrebreather mask.
The newly hired nurse has attended a continuing education conference regarding anaphylaxis
with allergen exposure. Which of the following statements by the newly hired nurse indicates a
need for further education?
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, -"The client may present with widespread hives and hypoxia."
-"The client may present with swollen lips and tongue".
-"The client may report new-onset abdominal cramping with hyperreflexia."
-"The client may have audible wheezes and cyanosis." - ANSWER -"The client may report new-
onset abdominal cramping with hyperreflexia."
The nurse is assessing a client who has systemic lupus erythematosus (SLE). Which findings from
the box below require follow-up by the nurse?
1. Prolonged capillary refill.
2. Cardiac murmurs.
3. Butterfly rash.
4. Joint pain.
5. Oliguria. - ANSWER -1. Prolonged capillary refill.
2. Cardiac murmurs.
5. Oliguria.
The nurse is teaching a 32-year old female client who has Systemic erythematosus (SLE) about
self-care practices. Which of the following statements by the client indicates the need for
additional teaching by the nurse?
-"I should inspect my skin daily for rashes."
-"I should carefully consider whether I should get pregnant again."
-"I should limit my exposure to direct sunlight to 30 continuous minutes each day."
-"I should check my temp. on a regular basis." - ANSWER -"I should limit my exposure to direct
sunlight to 30 continuous minutes each day."
The nurse working in the emergency department (ED) is caring for a group of assigned clients.
Which of the following clients should the nurse see first?
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ANSWER KEY NEURO-SHOCK & BURNS
PRACTICE GRADED A+
The nurse is caring for a client who has a liver transplant 48 hours ago. It is a priority for the
nurse to notify the PHCP if the client has
- An increasing bilirubin level
- Scant amounts of serosanguinous drainage from the incision
- A urine output that has decreased from 65 to 45mL/ Hr since surgery
- An increase in BP from 115/68 to 122/74 - ANSWER -An increasing bilirubin level
The nurse is caring for a client who had a lung transplant 10 days ago. It is a priority for the
nurse to notify the PHCP if the client has
- Only used the incentive spirometer once since last evening
- Developed sputum that is yellow-tinged
- A pain rating of 7/10 when taking a deep-breath
- Refused high- frequency chest wall oscillation for the past 24 hrs. - ANSWER -Developed
sputum that is yellow-tinged
The nurse is caring for a client who had a kidney transplant 2 week ago. Which findings from the
box below should the nurse correlate to possible organ rejection?
1|Page
,1. Blood pressure of 116/66
2. Serum creatinine lvl of 2.5
3. Urinalysis is positive for protein
4. Serum potassium level of 5.8
5. Blood urea nitrogen (BUN) levl of 30. - ANSWER -2. Serum creatinine lvl of 2.5
4. Serum potassium level of 5.8
5. Blood urea nitrogen (BUN) levl of 30.
The nurse working in the PHCP office has just administered a routine immunization to a client.
The client is asked to wait in the waiting room for the next 15 minutes. five minutes later, the
client develops swlling of the eyes and reports feeling anxious, SOB, and dizzy. Which of the
following actions should the nurse take first?
- Elevate the client's feet and legs
- Perform a respiratory assessment
- Prepare tp administer diphenhydramine
- Obtain a full set of vital signs. - ANSWER -Perform a respiratory assessment
The nurse working in the emergency department (ED) is admitting a client who presents with
stridor, dyspnea, and bronchospasm after being stung by a bee. After notifying the ED health
care provider, which of the following action should the nurse take next?
-Administer an Albuterol nebulizer treatment.
-Initiate oxygen via a nonrebreather mask.
-Remove the bee sting from the site of the sting.
-Prepare to administer a corticosteroid. - ANSWER -Initiate oxygen via a nonrebreather mask.
The newly hired nurse has attended a continuing education conference regarding anaphylaxis
with allergen exposure. Which of the following statements by the newly hired nurse indicates a
need for further education?
2|Page
, -"The client may present with widespread hives and hypoxia."
-"The client may present with swollen lips and tongue".
-"The client may report new-onset abdominal cramping with hyperreflexia."
-"The client may have audible wheezes and cyanosis." - ANSWER -"The client may report new-
onset abdominal cramping with hyperreflexia."
The nurse is assessing a client who has systemic lupus erythematosus (SLE). Which findings from
the box below require follow-up by the nurse?
1. Prolonged capillary refill.
2. Cardiac murmurs.
3. Butterfly rash.
4. Joint pain.
5. Oliguria. - ANSWER -1. Prolonged capillary refill.
2. Cardiac murmurs.
5. Oliguria.
The nurse is teaching a 32-year old female client who has Systemic erythematosus (SLE) about
self-care practices. Which of the following statements by the client indicates the need for
additional teaching by the nurse?
-"I should inspect my skin daily for rashes."
-"I should carefully consider whether I should get pregnant again."
-"I should limit my exposure to direct sunlight to 30 continuous minutes each day."
-"I should check my temp. on a regular basis." - ANSWER -"I should limit my exposure to direct
sunlight to 30 continuous minutes each day."
The nurse working in the emergency department (ED) is caring for a group of assigned clients.
Which of the following clients should the nurse see first?
3|Page
