ATI RN
ATI 410 Med Surg Exam Questions
Extract:
Question 1 of 5
A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?
Correct Answer: B
Rationale: An escharotomy involves incisions through the eschar to relieve pressure and improve blood flow, preventing complications like compartment syndrome. Other options describe different procedures.
Question 2 of 5
A nurse is caring for a client who has Meniere's disease. The nurse identifies which of the following manifestations is caused by an excessive accumulation of endolymph fluid?
Correct Answer: B
Rationale: Vertigo is a primary symptom of Meniere's disease, caused by excessive endolymph fluid in the inner ear affecting balance and spatial orientation. Myopia, photophobia, and presbycusis are unrelated to endolymph accumulation.
Question 3 of 5
A nurse is selecting a qualified staff member to double check a blood label with a client ID bracelet prior to infusing a unit of blood. The nurse should identify which of the following persons is qualified?
Correct Answer: D
Rationale: An oncology nurse is a registered nurse with specialized training and experience in administering blood products, making them qualified to double-check blood labels and patient identification. Phlebotomists, assistive personnel, and senior nursing students lack the required training or authority for this critical safety task.
Question 4 of 5
After radiation treatment, a client reports dryness, redness, and scaling of his skin occurring within the designated radiation treatment markings. The nurse should instruct the client to take which of the following actions?
Correct Answer: D
Rationale: Hydrating lotions soothe and moisturize skin, alleviating dryness and scaling from radiation. Other options risk further irritation or damage.
Extract:
Nurse's Notes:
Client admitted to the unit for a lower GI bleed. Continues to have frequent bloody stools and is scheduled for a lower endoscopy in 4 hr. The client is receiving their fourth unit of packed red blood cells (packed RBCs). Unit of fourth packed RBCs started at a rate of 250 cc/hr. Thirty minutes after the transfusion started, the client started reporting dyspnea and restlessness. Crackles auscultated in bilateral lower lobes. oxygen saturation 92% on 2L nasal cannula, and jugular vein distention noted.
Vital signs:
Temperature: 37.0°C (98.6°F)
Heart Rate (HR): 110 beats per minute
Blood Pressure (BP): 150/90 mmHg
Respiratory Rate (RR): 24 breaths per minute
Oxygen Saturation (SpO2): 92% on 2L nasal cannula
Question 5 of 5
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
Correct Answer: B,C,D
Rationale: The client is experiencing transfusion-associated circulatory overload (TACO), indicated by dyspnea, crackles, jugular vein distention, and hypertension. Stopping the transfusion prevents further fluid overload, and furosemide removes excess fluid. Monitoring weight and respiratory rate assesses fluid status and respiratory distress.