ATI RN
ATI Med Surg Custom N235 Final Summer 2023 Questions
Extract:
Question 1 of 5
A nurse in a critical care unit is caring for a client 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: D
Rationale: Muffled heart sounds are a classic sign of cardiac tamponade due to pericardial fluid accumulation.
Question 2 of 5
A nurse is caring for a client who has a traumatic brain injury. The nurse notes that the client has a widening pulse pressure. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Widening pulse pressure suggests increased ICP; elevating the head to 30° reduces it.
Question 3 of 5
A nurse is assessing a client in the oliguric phase of acute kidney injury. Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: Hyperkalemia is expected in the oliguric phase of AKI due to reduced potassium excretion.
Question 4 of 5
A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take?
Correct Answer: D
Rationale: Elevating the head (typically 30°, but 20° here) reduces ICP by aiding venous drainage.
Question 5 of 5
A client who is having burn debridement states, 'You are the worst nurse I have ever seen. All you do is hurt me.' Which of the following responses should the nurse make?
Correct Answer: D
Rationale: Tell me more about that' encourages the client to express feelings, promoting therapeutic communication.