ATI RN
ATI Medsurg Exam 5 Questions
Extract:
Question 1 of 5
A client came to the Emergency Department with nausea and vomiting. Which of the following will the nurse include in the client's database?
Correct Answer: C
Rationale: In an emergency, the nurse prioritizes data relevant to immediate treatment, such as vital signs and fluid balance, over comprehensive histories or unrelated data.
Question 2 of 5
The nurse documents the blood pressure on a client to be 158/94 mm Hg when lying in bed, 13 mm Hg when sitting in a chair, and 98/60 mm Hg when standing. The nurse should recognize which of the following as the evaluation of this?
Correct Answer: A
Rationale: The significant drop in blood pressure upon standing indicates orthostatic hypotension, not hypertension or normal variation.
Question 3 of 5
The nurse is caring for a client with stage 2 pressure ulcer. The nurse should document which of the following as characteristic of a stage II pressure ulcer?
Correct Answer: D
Rationale: Stage II pressure ulcers involve partial-thickness loss with open blisters and a red-pink wound bed, not eschar or subcutaneous involvement.
Question 4 of 5
The nurse is caring for a client who reports a lump below the 'Adam's apple.' Which of the following assessment findings should the nurse recognize as a non-cancerous lump?
Correct Answer: D
Rationale: A mobile and soft lump is typically benign, unlike hard, fixed, or irregular lumps, which suggest malignancy.
Question 5 of 5
The nurse is performing an examination of the client's face. The nurse should recognize that which two of the salivary glands are accessible during facial examination?
Correct Answer: A
Rationale: The parotid and submandibular glands are palpable during facial examination, unlike sublingual or non-salivary glands like occipital.