Med Surg 1 ATI 2023
2 yr old normal vital signs – ANSWER Temp: 97.5-98.6
Pulse: 70-110
RR: 20-30
4 yr old normal vital signs – ANSWER Temp: 97.5-98.6
Pulse: 66-110
RR: 20-25
10 yr old normal vital signs – ANSWER Temp: 97.5-98.6
Pulse: 60-95
RR: 14-22
16 yr old normal vital signs – ANSWER Temp: 97.5-98.6
Pulse: 55-85
RR: 12-18
A 70 kg postoperative pt has an average urine output of 25 mL/hr during the first
8 hours. The PRIORITY nursing interventions giving this assessment would be…
a) notify the surgeon and expect obtaining blood work to evaluate renal function
b) perform a straight cath to measure the amount of urine in the bladder
c) continue to monitor the pt bc this is a normal finding during this time period
d) evaluate the pts fluid volume status since surgery and obtain a bladder
ultrasound – ANSWER d) evaluate the pts fluid volume status since
surgery and obtain a bladder ultrasound
A client is admitted to the emergency department following a motorcycle crash.
The nurse notes a crackling sensation upon palpation on the right side of the
client’s chest. After notifying the provider, the nurse should document this finding
as which of the following?
a) friction rub
b) crackles
c) crepitus
d) tactile fremitus – ANSWER c) crepitus
Crepitus, also called subcutaneous emphysema, is a coarse crackling sensation
that the nurse can feel when palpating the skin surface over the client’s chest.
Crepitus indicates an air leak into the subcutaneous tissue, which is often a clinical
manifestation of a pneumothorax.
A community health nurse is providing teaching about malignant melanoma to a
group of clients. the nurse should inform the group that which of the following
traits places a client at risk for developing malignant melanoma?
a) brown eyes
b) light skin
c) black hair
d) dark skin – ANSWER b) light skin
A diagnosis of AIDS can be made for a pt with HIV with:
a) A CD4+T cell count <500/uL
b) A WBC count <3000/uL
c) Development of oral candidiasis (thrush)
d) Onset of Pneumocystis jiroveci pneumonia – ANSWER d) Onset of
Pneumocystis jiroveci pneumonia
A heterosexual patient is concerned that they may contract human
immunodeficiency virus (HIV) from a bisexual partner. What should the nurse
include when teaching about preexposure prophylaxis? (Select all that apply.)
a) Take fluconazole (Diflucan).
b) Take amphotericin B (Fungizone).
c) Use condoms for risk-reducing sexual relations.
d) Take emtricitabine and tenofovir (Truvada) regularly.
e) Have regular HIV testing for herself and her husband. – ANSWER
c) Use condoms for risk-reducing sexual relations.
d) Take emtricitabine and tenofovir (Truvada) regularly.
e) Have regular HIV testing for herself and her husband.
A nurse in a provider’s office is assessing a client who states he was recently
exposed to tuberculosis. Which of the following findings is a clinical manifestation
of pulmonary tuberculosis?
a) pericardia friction rub
b) weight gain
c) night sweats
d) cyanosis of the fingertips – ANSWER c) night sweats
Night sweats and fevers are clinical manifestations of tuberculosis.
A nurse in an urgent care clinical is collecting data from a client who reports
exposure to anthrax. Which of the following finding is an indication of the
prodromal stage of inhalation anthrax?
a) dry cough
b) rhinitis
c) sore throat
d) swollen lymph nodes – ANSWER a) dry cough
A dry cough is a clinical manifestation found in the prodromal stage of having
inhalation anthrax. During this stage, it is difficult to distinguish from influenza or
pneumonia because there is no sore throat or rhinitis.
A nurse in the ED is assessing a client for a closed pneumothorax and significant
bruising of the left chest following a motor-vehicle crash. The client reports