ATI Med-Surg 2 (NUR 265) – Neuro, Shock & Burns Practice Questions with Detailed Answer Key [Updated]

NUR 120: ADVANCED MEDSURG FINAL FOR LUCKY STUDENTS




ATI MEDSURG 2 NUR
265/ DETAILED ANSWER
KEY NEURO-SHOCK
& BURNS PRACTICE updated

I. The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient
with right lower lobe pneumonia. The nurse should intervene if which action by UAP is
observed?


a. UAP splint the patient’s chest during
coughing.

b. UAP assist the patient to
ambulate to the bathroom.

c. UAP help the patient to a bedside chair for
meals.

d. UAP lower the head of the patient’s bed
to 15 degrees.

, NUR 120: ADVANCED MEDSURG FINAL FOR LUCKY STUDENTS

ANS: D


Positioning the patient with the head of the bed lowered will decrease ventilation. The other
actions are appropriate for a patient with pneumonia.



DIF: Cognitive Level: Apply (application) REF: 527


OBJ: Special Questions: Delegation TOP: Nursing Process:
Implementation MSC: NCLEX: Safe and Effective Care Environment




II. A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough, and an
g g g g g g g g g g g g g g g g g




oxygen saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to
g g g g g g g g g g g g g g




get out of bed. Which nursing diagnosis should the nurse assign as the highest priority?
g g g g g g g g g g g g g g g g



g g




a. g g Hyperthermia related to infectious illness g g g g g g




b. g g Impaired transfer ability related tog g g g g



weakness g g




c. g g Ineffective airway clearance related g g g g



to thick secretions
g g g g




d. g g Impaired gas exchange g g g related g to g




respiratory congestion g g g




g g


g g




ANS: D g g g



g g




All these nursing diagnoses are appropriate for the patient, but the patient’s oxygen saturation
g g g g g g g g g g g g g g




indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved.
g g g g g g g g g g g g g g g g g



g g




g DIF: Cognitive Level: Apply (application)
g g g g g g REF: g g 527 g g



g g




OBJ: Special Questions: Prioritization
g g g g g TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integr
g g g g g g g




III. A patient with a possible pulmonary embolism complains of chest pain and difficulty
g g g g g g g g g g g g g




breathing. g g

, NUR 120: ADVANCED MEDSURG FINAL FOR LUCKY STUDENTS


The nurse finds a heart rate of 142 beats/minute, blood pressure of 100/60 mmHg, and
g g g g g g g g g g g g g g g




respirations of 42 breaths/minute. Which action should the nurse take first?
g g g g g g g g g g g g



g g



a. g g Administer anticoagulant drug therapy. g g g g g




b. g g Notify the patient’s health care provider.
g g g g g g g




c. g g Prepare patient for a spiral computedg g g g g g



tomography (CT). g g g




d. g g Elevate the head of the bed to a g g g g g g g g



semiFowler’s position. g g g




g g


g g




ANS: D g g g



g g




The patient has symptoms consistent with a pulmonary embolism (PE). Elevating the head of the
g g g g g g g g g g g g g g




g bed will improve ventilation and gas exchange. The other actions can be accomplished after the
g g g g g g g g g g g g g g g




head is elevated (and oxygen is started). A spiral CT may be ordered by the health care provider
g g g g g g g g g g g g g g g g g g




to identify PE. Anticoagulants may be ordered after confirmation of the diagnosis of PE.
g g g g g g g g g g g g g g g




g DIF: Cognitive Level: Apply (application)
g g g g g g REF: g g 553 g g



g g




OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:
g g g g g g g g




g NCLEX: Physiological Integrity g g g g



g g




IV. The nurse receives change-of-shift report on the following four patients. Which patient should
g g g g g g g g g g g g g




the nurse assess first?
g g g g g



g g



a. g g A 23-year-old patient with cystic fibrosis
g g g g g g



who has pulmonary function testing
g g g g g



scheduled g g




b. g g A 46-year-old patient on bed rest who is
g g g g g g g g



complaining of sudden onset of shortness g g g g g



of breath
g g g g

, NUR 120: ADVANCED MEDSURG FINAL FOR LUCKY STUDENTS

c. g g A 77-year-old patient with tuberculosis
g g g g g



(TB) who has four antitubercular
g g g g g



medications due in 15 minutes g g g g g g




d. g g A 35-year-old patient who was
g g g g g




admitted the previous day with g g g g g




pneumonia and has a temperature of g g g g g g g




100.2° F (37.8° C) g g g g g




g g


g g
g g




ANS: B g g g



g g




Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden
g g g g g g g g g g g g g g g g g




onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism and
g g g g g g g g g g g g g g g g




requires immediate assessment and action such
g g g g g g g g




as oxygen administration. The other patients should also be assessed as soon as possible, but
g g g g g g g g g g g g g g g




there is no indication that they may need immediate action to prevent clinical deterioration.
g g g g g g g g g g g g g g g



g g




g DIF: Cognitive Level: Analyze (analysis)
g g g g g g REF: 551-553 g g g



g g




OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Planning MSC:
g g g g g g g g g g g




g NCLEX: Safe and Effective Care Environment
g g g g g g g



g g




V. The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have
g g g g g g g g g g g g g g g g




g immigrated to the United States. Which question is most important for the nurse to ask before
g g g g g g g g g g g g g g g g




the skin test?
g g g g



g g



a. g g “Is there any family history of TB?”
g g g g g g g g




b. g g “How long have you lived in the United
g g g g g g g g g




States?” g g




c. g g “Do you take any over-the-counter
g g g g g g




(OTC) medications?” g g g




d. g g “Have you received the bacille g g g g g g




Calmette-Guérin (BCG) vaccine for g g g g g




TB?” g g



g g


g g