ATI EW N300 Med Surg Exam

Question 1 of 5

The nurse is caring for a client who has had a stroke and who has received tissue plasminogen activator (t-PA). Which of the following symptoms would prompt the nurse to stop the infusion of t-PA?

A. Decreased level of consciousness.B. Elevated blood pressure and patient reports headache.C. Patient has vomited once and reports persistent nausea.D. Positive Babinski's sign.E. Fever and cardiac dysrhythmias.

Correct Answer: A,B,C

Rationale: Decreased consciousness, elevated blood pressure with headache, and vomiting with nausea suggest intracranial hemorrhage, a serious complication requiring immediate cessation of t-PA.

Question 2 of 5

The nurse is caring for a patient with a spinal cord injury at the level of C-7. The patient is having a severe headache, hypertension, bradycardia, diaphoresis, and flushing of the face with pale, cold skin below the level of the injury. What are the priority nursing interventions?

A. Elevate the head of the bed, loosen clothing, check the urinary catheter for obstruction.B. Elevate the head of the bed and apply a cool compress to the forehead.C. Establish IV access, apply 2L of oxygen via nasal cannula, notify provider.D. Place in supine position and establish IV access for medication administration.

Correct Answer: A

Rationale: These interventions address autonomic dysreflexia by reducing blood pressure and removing triggers like catheter obstruction.

Question 3 of 5

The client who is diagnosed with a seizure disorder is prescribed a ketogenic diet. The nurse knows that the client understands the teaching when they state:

A. My diet will include more unsaturated fats and low carbohydrates.B. My diet will include increased amounts of carbohydrates and protein.C. My diet will include moderate amounts of protein and omega-3 oils.D. My diet will include foods rich in sodium and carbohydrates.

Correct Answer: A

Rationale: A ketogenic diet is high in fats, low in carbohydrates, and moderate in protein, promoting ketosis to reduce seizure frequency.

Question 4 of 5

The nurse is caring for a patient diagnosed with a traumatic head injury secondary to a work accident. In the morning assessment, the patient opened his eyes in response to noxious stimuli. Two hours later, what assessment finding would warrant immediate action by the nurse? The patient:

A. Can squeeze the nurse's hand upon verbal request.B. Follows simple commands with repetition/prompting from nurse.C. Has purposeful movement when the nurse rubs the sternum.D. Extends upper and lower extremities in response to painful stimuli.

Correct Answer: D

Rationale: Extending extremities in response to painful stimuli, known as decerebrate posturing, is a severe neurologic deficit indicating brainstem dysfunction and requires immediate nursing intervention.

Question 5 of 5

The nurse is caring for a patient with epilepsy who has recently had a change in their prescribed medication combination. Which of the following options are priority to institute?

A. Soft restraints, suction equipment, a penlight.B. An intravenous pump at bedside, copy of a Glasgow Coma Scale (GCS).C. Suction equipment, oxygen, patent IV access.D. Bed alarm, primed IV line of 5% Dextrose in water.

Correct Answer: C

Rationale: Suction equipment and oxygen are vital in epilepsy management to clear secretions and maintain oxygenation during seizures. Patent IV access allows rapid administration of emergency medications.

ATI EW N300 Med Surg Exam | Nurselytic

Nurselytic

ATI RN

ATI RN