ATI NUR 213 Midpoint Assessment FA II 2025 Assessment I

Explanation
B. Ciprofloxacin​
Antibiotics such as ciprofloxacin may be prescribed during severe flare-ups of ulcerative colitis
when there is concern for secondary infection. Although not used routinely, it may be used when
complications such as abscess or infection are suspected.
E. Golimumab​
Golimumab is a biologic (TNF inhibitor) approved for use in moderate to severe ulcerative
colitis. It reduces inflammation by suppressing immune responses and is often used when other
medications fail to control symptoms effectively.
F. Methylprednisolone​
Corticosteroids like methylprednisolone are used during acute flare-ups to rapidly decrease
inflammation. They are not used long-term but are appropriate for induction therapy to control
severe symptoms and promote remission.

Explanation
A. Apply compression stockings​
Compression stockings improve venous return by applying external pressure to the lower
extremities. This helps prevent venous stasis, which is a major contributor to deep vein
thrombosis (DVT) and pulmonary embolism. They are a standard preventive measure after
surgery and should be applied as early as possible unless contraindicated. C. Encourage the client to do active leg exercises​
Postoperative clients often have limited mobility, which increases their risk of clot formation.
Active leg exercises mimic normal muscle contractions, enhance circulation, prevent venous
pooling, and help reduce the risk of DVT. Exercises such as ankle pumps, leg lifts, and foot
circles should be encouraged early.
E. Ambulate the client safely​
Early ambulation is one of the most effective interventions to prevent pulmonary embolism.
Walking promotes blood flow, stimulates deep breathing, expands the lungs, and prevents venous
stasis. Ambulation should begin as soon as safely possible following surgery and anesthesia
recovery.

Explanation
Explanation of Correct Answer (C):​
When major burns occur, massive cell destruction leads to the release of large amounts of
intracellular potassium into the bloodstream. A potassium level of 6.0 mg/dL indicates
hyperkalemia, which is a dangerous sign of cellular breakdown and can lead to life-threatening
cardiac arrhythmias. This value requires immediate intervention to prevent cardiac
complications.

Explanation
The first priority in sepsis management is to obtain lactate level and blood cultures to evaluate
the severity of infection and identify the causative pathogen before starting antibiotics. The
second priority is to administer rapid infusion of IV fluid to restore circulating volume and
improve tissue perfusion. The third priority is administer vasopressors if hypotension persists
despite fluid resuscitation. Finally, broad-spectrum antibiotics are administered after cultures are
collected to treat the infection promptly.

Explanation
B. Loss of protein​
Burns, especially when covering a significant portion of the body, cause extensive damage to the
skin and underlying tissues. This damage leads to the loss of proteins such as albumin and
globulins, which normally help maintain the balance of fluids within the blood vessels. As
protein is lost through the burn wounds, this can result in hypoalbuminemia, which contributes
to edema and worsens fluid shifts between the intracellular, intravascular, and interstitial spaces.
The body’s inability to retain enough protein increases the risk of hypovolemic shock and
delayed wound healing.
C. Diuresis​
Following the initial phase of burn injury, the body undergoes a hypermetabolic state and
experiences fluid shifts. The kidneys respond to these fluid shifts by increasing urine output,
known as diuresis, as part of the body’s compensatory mechanisms. This process is essential for
eliminating excess fluid that accumulates during the acute phase of burns. Diuresis is also
influenced by fluid resuscitation therapy (e.g., using fluids like lactated Ringer's solution),
which temporarily expands the extracellular volume. However, excessive diuresis can lead to
electrolyte imbalances and dehydration if not carefully monitored.
D. Decreased plasma volume​
In the initial stage of a severe burn injury, there is a dramatic decrease in plasma volume due to
the capillary leak syndrome. Burn-induced injury to the endothelial cells of blood vessels causes
them to become more permeable, allowing fluid, proteins, and electrolytes to leak from the
vascular system into the interstitial and intracellular spaces. This causes a reduction in the
circulating blood volume, contributing to hypovolemia. This reduction in plasma volume can
result in shock and requires immediate and aggressive fluid resuscitation to restore normal blood
volume and blood pressure.
E. Capillary leak​
One of the most significant consequences of severe burns is the capillary leak syndrome, where
the permeability of blood vessels increases significantly due to the inflammatory response
triggered by the burn injury. The affected blood vessels lose their ability to maintain a selective
barrier, allowing fluid and proteins (including albumin) to leak out of the vessels and
accumulate in the interstitial spaces. This leads to edema, and in some cases, shock if the fluid

Explanation
In the early phase of burn injury, fluid loss and hypovolemia cause an increase in heart rate as
the body compensates for the decreased circulating blood volume. As adequate fluid
replacement occurs, the heart rate should decrease, indicating that the body is no longer in a
compensatory state of shock. This decrease in heart rate is a positive sign of improved
circulatory volume and the effectiveness of fluid resuscitation.

Explanation
Explanation of Correct Answer (C):
In the compensatory stage of shock, the body activates mechanisms to maintain perfusion to
vital organs. One key sign is altered mental status, including confusion, restlessness, or anxiety,
caused by decreased cerebral perfusion. The blood pressure often remains within normal or

Explanation
A. Inspect the sacrum for blanching​
Early assessment helps detect tissue damage before breakdown occurs. Checking for blanching
identifies impaired circulation and allows interventions before a pressure injury develops.
C. Optimizing nutrition​
Proper nutrition, especially protein, vitamins, and hydration, promotes tissue repair and skin
integrity. Malnutrition increases the risk of pressure ulcers and delays healing.
D. Frequent turning and positioning​
Repositioning at regular intervals reduces prolonged pressure on bony prominences. Turning
every 2 hours is a standard intervention to prevent pressure injuries.
E. Frequent skin assessments​
Ongoing inspection allows early identification of redness, moisture, or irritation. Monitoring
high-risk areas ensures timely care and prevents skin breakdown.

Explanation
A. Admit to a negative pressure room​
Patients with suspected or confirmed active TB must be placed in airborne isolation using a
negative pressure room. This prevents the spread of Mycobacterium tuberculosis by keeping air
from escaping into the hallway and protecting others in the facility.
C. Collect specimen x3 mornings for acid-fast bacilli​
The most definitive diagnostic test for active TB is sputum culture for acid-fast bacilli (AFB).
Three early-morning specimens are collected on separate days. This is essential for laboratory
confirmation and guides treatment.
E. CBC, BMP, HIV viral load, VDRL​
Patients with active TB should be assessed for possible comorbidities and coinfections such as
HIV and syphilis. CBC and BMP also help evaluate overall health and organ function before
starting treatment, as TB therapy can be hepatotoxic.