ATI RN
ATI Med Surg Custom N235 Final Summer 2023 Questions
Extract:
Question 1 of 5
A nurse in an emergency department is caring for an adult client who has burns on the front and back of both his legs and arms. Using the rule of nines, the nurse should document burns to which percentage of the client's total body surface area (TBSA)?
Correct Answer: A
Rationale: Rule of nines: each arm (18%) + each leg (18%) = 9% × 4 (front and back) = 54% TBSA.
Question 2 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.
Question 3 of 5
A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care?
Correct Answer: B
Rationale: In trauma situations, the priority is to ensure a patent airway (airway protection) as per the ABCs (Airway, Breathing, Circulation) of emergency care, since oxygenation is critical for survival.
Question 4 of 5
A nurse is reviewing the arterial blood gas results for a client in the ICU who has kidney failure and determines the client has respiratory acidosis. Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: Widened QRS complexes can occur in respiratory acidosis due to hyperkalemia from kidney failure.
Question 5 of 5
A nurse in the emergency department is caring for a client who has sustained a head injury. The nurse notes the client's IV fluids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse?
Correct Answer: C
Rationale: In head injury, rapid fluid infusion (125 mL/hr) can worsen ICP; slowing to 20 mL/hr is safer.