Questions 49

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ATI RN Test Bank

ATI Med Surg 2 Questions

Question 1 of 5

A nurse is helping to triage a group of clients at a mass casualty incident who were involved in an explosion at a local factory. Which of the following clients should the nurse tag to be the priority for care?

Correct Answer: D

Rationale: This is correct because this client has a life-threatening condition called tension pneumothorax, which requires immediate care. The hissing sound indicates air escaping from the lung, necessitating urgent intervention.

Question 2 of 5

A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency?

Correct Answer: A

Rationale: Cold and numb sensation distal to the fistula site indicates venous insufficiency due to reduced venous return.

Question 3 of 5

A nurse is performing a neurological assessment for a client who has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III?

Correct Answer: B

Rationale: Instructing the client to look up and down assesses cranial nerve III (oculomotor), which controls eye movements.

Question 4 of 5

A nurse is planning a staff education session regarding biological weapons of mass destruction. Which of the following should he plan to include in the session?

Correct Answer: A,C,D

Rationale: Correct choices include smallpox, botulism, and anthrax, which are biological agents. Hydrogen cyanide and sarin are chemical weapons.

Question 5 of 5

A nurse in the emergency department is caring for a client who sustained a head injury. The nurse notes the client's IV fluids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse?

Correct Answer: C

Rationale: Continuing at 125 mL/hr maintains hydration without risking fluid overload or increased intracranial pressure.

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