ATI RN
ATI Med Surg Exam 9 Questions
Question 1 of 5
A client diagnosed with a sty of the eye asks what can be done for treatment. Which of the following options will the nurse provide to the client?
Correct Answer: B
Rationale: Reason: An antifungal cream is not indicated for a sty, which is an infection of the eyelash follicle or sebaceous gland caused by bacteria. Reason: This is the correct answer because warm compresses can help relieve pain and inflammation, and promote drainage of the sty. Reason: Ice and cold compresses are not recommended for a sty, as they can constrict blood vessels and delay healing. Reason: There is no need to test the other eye for vision loss, as a sty does not affect vision unless it is very large or obstructs the pupil.
Question 2 of 5
A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider?
Correct Answer: D
Rationale: Reason: A heart rate of 122/min is elevated, but not life-threatening. It could be due to pain, anxiety, dehydration, or infection. Reason: A urinary output of 25 ml/hr is low, but not critical. It could indicate fluid loss, kidney damage, or inadequate fluid resuscitation. Reason: A pain level of 6 on a scale of 0 to 10 is moderate, but not severe. It could be managed with analgesics and non-pharmacological interventions. Reason: This is the correct answer because difficulty swallowing can indicate airway obstruction, inhalation injury, or edema of the throat. It can compromise breathing and require immediate intervention.
Question 3 of 5
A client arrives to the clinic with reports of progressive weakness in his lower extremities. Which of the following findings in the client's history is consistent with the client developing Guillain-Barre syndrome?
Correct Answer: D
Rationale: Reason: A facial tumor is not related to Guillain-Barre syndrome, which is an autoimmune disorder that affects the peripheral nerves. Reason: Pregnancy is not a risk factor for Guillain-Barre syndrome, although it can occur during or after pregnancy in rare cases. Reason: A puncture wound 3 weeks ago is unlikely to cause Guillain-Barre syndrome, which usually follows a respiratory or gastrointestinal infection. Reason: This is the correct answer because cytomegalovirus is one of the common infections that can trigger Guillain-Barre syndrome. It can cause inflammation and damage to the myelin sheath that covers the nerves.
Question 4 of 5
The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the primary health care provider?
Correct Answer: B
Rationale: Reason: Soft pasty stool is normal for a transverse colostomy, as the stool has not reached the sigmoid colon where most of the water is absorbed. Reason: This is the correct answer because purple discoloration of the stoma indicates ischemia or necrosis, which can lead to infection, perforation, or sepsis. It requires urgent intervention. Reason: Stoma is beefy red is a normal finding for a healthy stoma, as it indicates adequate blood supply and healing. Reason: There is skin excoriation around the stoma is a common complication of a colostomy, as the stool can irritate the skin. It can be managed with proper skin care and appliance fitting.
Question 5 of 5
A nurse in the emergency department is caring for a client following an automobile crash in which the client was unrestrained and thrown from the vehicle. When assessing the client, the nurse observes clear fluid draining from the client's nose. Which of the following interventions should the nurse take?
Correct Answer: C
Rationale: Reason: Inserting a nasal swab to observe the fluid is not recommended because it can potentially harm the patient. If the fluid draining from the nose is cerebrospinal fluid (CSF), which is a clear, colorless body fluid found in the brain and spinal cord, inserting a swab could introduce bacteria into this sterile environment. This could lead to serious complications such as meningitis, an inflammation of the membranes surrounding the brain and spinal cord. Reason: Suctioning the nose gently with a bulb syringe is also not recommended. Again, if the fluid is CSF, suctioning could potentially draw bacteria up into the nasal cavity and into the brain, leading to an increased risk of infection. Additionally, suctioning could potentially cause trauma to the nasal passages, leading to further complications. Reason: Allowing the drainage to drip onto a sterile gauze pad is the safest option. This method avoids the risk of introducing infection into the CSF and allows for the fluid to be tested to confirm if it is CSF. If the fluid is indeed CSF, this could indicate a basilar skull fracture, a serious injury that requires immediate medical attention. Reason: Inserting sterile packing into the nares is not recommended. While this might seem like a good way to stop the drainage, it could actually be very dangerous. If the fluid is CSF, the packing could act as a conduit, drawing bacteria up into the brain and leading to infection. Additionally, the packing could cause pressure on the brain if the fluid continues to drain but has nowhere to go.