ATI RN
ATI Adult Med Surg Nurs 4292 Exam Questions
Extract:
Question 1 of 5
A client who has a recent closed head injury reports a severe headache and is restless. Which of the following is an appropriate nursing intervention?
Correct Answer: B
Rationale: Elevating the HOB decreases intracranial pressure which may be causing the headache.
Question 2 of 5
The nurse is assessing for asterixis in a client with cirrhosis. How should the nurse assess for asterixis?
Correct Answer: B
Rationale: Asterixis (liver flap) is assessed by having patient extend arms and observing for involuntary flapping motions.
Question 3 of 5
A nurse is reviewing the BUN and creatinine levels of an older adult client who has chronic kidney disease (CKD). Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: Elevated BUN and creatinine reflect impaired kidney function in CKD.
Question 4 of 5
A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator-associated pneumonia?
Correct Answer: A
Rationale: Regular oral care reduces bacterial colonization that could lead to VAP.
Question 5 of 5
A nurse is assessing a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?
Correct Answer: C
Rationale: Decreased LOC is the earliest and most sensitive sign of increased ICP.