ATI Advanced Med Surg Exam 4

Question 1 of 5

An unresponsive 79-yr-old patient is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 105.4° F (40.8° C), blood pressure (BP) is 88/50 mm Hg, and pulse is 112 beats/min. What action should the nurse plan to take?

A. Give acetaminophen (Tylenol) rectal suppository.B. Provide O2 at 2 L/min with a nasal cannula.C. Apply wet sheets and a fan to the patientD. Start lactated Ringer's solution at 1000 mL/hr

Correct Answer: C

Rationale: Applying wet sheets and a fan rapidly lowers core temperature to prevent organ damage.

Question 2 of 5

Following an earthquake, patients are triaged by emergency medical personnel and transported to the emergency department (ED). Which patient will the nurse need to assess first?

A. A patient with a blue tagB. A patient with a black tagC. A patient with a yellow tagD. A patient with a red tag

Correct Answer: D

Rationale: Red-tagged patients have critical conditions requiring immediate assessment.

Question 3 of 5

A nurse is assisting with triaging clients following an explosion. Which of the following clients should the nurse identify as the highest priority?

A. A conscious adult client who has second-degree burns on both lower legs; respiratory rate is > 30/minB. A conscious adult client wearing a medic-alert diabetic bracelet, client reports feeling clammy and shaky.C. An unconscious adult client who has a large head wound with gray matter exposed; absent respirationsD. An unconscious 6-month-old infant with no respirations, no visible injuries

Correct Answer: C

Rationale: Unconscious client with severe head injury and no respirations requires immediate intervention.

Question 4 of 5

A patient arrives in the emergency department (ED) several hours after taking "25 to 30" acetaminophen (Tylenol) tablets. Which action will the nurse plan to take?

A. Start oxygen using a non-rebreather mask,B. Have the patient drink large amounts of water.C. Give N-acetylcysteine.D. Discuss the use of chelation therapy.

Correct Answer: C

Rationale: N-acetylcysteine prevents liver damage in acetaminophen overdose.

Question 5 of 5

A nurse is caring for a client who has heart failure and a prescription for digoxin 125 mcg PO daily. Available is digoxin PO 0.25 mg/tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer: 0.5

Rationale: 125 mcg = 0.125 mg. Available is 0.25 mg/tablet. 0.125 ÷ 0.25 = 0.5 tablets.

ATI Advanced Med Surg Exam 4 | Nurselytic

Nurselytic

ATI RN

ATI RN