Questions 52

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ATI n300 Med Surg Exam Questions

Extract:


Question 1 of 5

A client has sustained a crush injury to the abdomen as the result of an industrial accident. The initial assessment and interventions have been carried out. The vital signs are stable and the family is at the bedside. The client is complaining of bilateral flank pain. What is the priority nursing action for this client now?

Correct Answer: D

Rationale: Flank pain after a crush injury suggests possible rhabdomyolysis or kidney damage. Testing urine for myoglobinuria or hematuria is the priority.

Question 2 of 5

A heparin IV bolus is ordered: 80 units per kilogram. The unit's pharmacist prepares & labels a dose of heparin that is 5600 units. What is the patient's weight in kilograms?

Correct Answer: A

Rationale: 5600 units ÷ 80 units/kg = 70 kg.

Question 3 of 5

A nurse is performing an initial interview of a client who has a neurologic deficit. Which actions by the nurse are MOST appropriate? (SELECT ALL THAT APPLY)

Correct Answer: A,C,D,E

Rationale: Establishing trust, observing physical signs, reviewing medications, and assessing substance use are critical for a comprehensive neurological assessment.

Question 4 of 5

The nurse is caring for an elderly client with type II diabetes who has had nausea, vomiting and diarrhea for several days and who now is disoriented and listless. Initial vital signs: B/P 72/62, pulse 146 irregular and thready, respirations 38 breaths per minute and shallow, and temperature of 97.0 F rectally. The skin is cool and clammy. The nurse recognizes that this client's symptoms are most indicative of which stage and type of shock? The:

Correct Answer: C

Rationale: The client shows signs of hypovolemic shock from fluid loss, with progressive stage indicated by hypotension, tachycardia, and altered mental status.

Question 5 of 5

A patient is ordered 1 unit of packed red blood cells (250mL) to be transfused over 120 minutes. The drop factor on the tubing is 15 gtt/mL. At what rate should the nurse regulate the IV (gtt/min)? (round to the nearest whole number)

Correct Answer: A

Rationale: Flow rate = (
Total volume × Drop factor) ÷ Time in minutes = (250 × 15) ÷ 120 = 31.25, rounded to 31 gtt/min.

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