ATI RN
ATI nur330 Med Surg Exam Questions
Question 1 of 5
A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?
Correct Answer: A
Rationale: Muffled heart sounds are a hallmark finding in cardiac tamponade due to fluid accumulation in the pericardial sac, which dampens the sound of the heart. Flattened neck veins are inconsistent with cardiac tamponade; distended neck veins are commonly seen. Tachycardia, not bradycardia, is a compensatory response. Lethargy is not specific to cardiac tamponade.
Question 2 of 5
A nurse is caring for a client who has a traumatic brain injury (TBI). Which of the following should the nurse understand is a possible consequence of a TBI?
Correct Answer: C
Rationale: TBIs cause mechanical disruption to brain cells and vasculature, leading to secondary effects such as swelling, ischemia, and cellular dysfunction. Increased blood supply is not typical; blood flow may be impaired. Increased intracranial pressure, not decreased, is likely. Pressure does not enhance synaptic connections.
Question 3 of 5
A nurse is caring for a client who has severe burns. Which of the following actions should the nurse take when caring for a client with severe burns?
Correct Answer: B,D
Rationale: Severe burns require pain management with opioid analgesics due to excruciating pain and benzodiazepines to manage anxiety. Cooling with ice water can cause vasoconstriction and worsen tissue damage; tepid water is preferred. Systemic antibiotics are not routine unless infection is present. Laying the bed flat is inappropriate as raising the head helps maintain airway patency.
Question 4 of 5
The nurse is providing care for a patient that is scheduled for a balloon valvuloplasty. The nurse recalls that balloon valvuloplasty is most commonly used for which valvular heart disease?
Correct Answer: B
Rationale: Balloon valvuloplasty is commonly used to relieve mitral valve stenosis by improving valve opening, often due to rheumatic heart disease. It is not effective for regurgitation disorders or mitral valve prolapse, which require surgical interventions.
Question 5 of 5
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect?
Correct Answer: A,C,D
Rationale: Fluid overload causes tachycardia to compensate for increased volume, hypertension due to increased vascular resistance, and tachypnea from pulmonary congestion. Hematocrit is typically decreased due to dilution. Temperature is not directly affected unless infection is present.