ATI RN
ATI SP 250 Exam 3 Med Surg Exam Questions
Extract:
Question 1 of 5
A nurse in an emergency room is caring a the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?
Correct Answer: C
Rationale: This is because inhalation injuries can compromise the airway and cause respiratory distress or failure, which can be life-threatening. The nurse should assess for signs such as soot, burns, hoarseness, or stridor.
Question 2 of 5
A nurse is caring for a client who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications?
Correct Answer: A,C,D
Rationale: These interventions can help prevent complications such as stress ulcers, ventilator-associated pneumonia, and aspiration. Pantoprazole reduces gastric acid secretion and protects the mucosa from erosion. Verifying the ventilator settings ensures that the client is receiving adequate oxygenation and ventilation according to their needs and goals. Elevating the head of the bed reduces the risk of aspiration and improves lung expansion.
Question 3 of 5
A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?
Correct Answer: D
Rationale: This is because burns to the face, neck, and upper extremities can compromise the airway, circulation, and mobility of the client. The nurse should monitor for signs of respiratory distress, infection, and contractures in these areas.
Question 4 of 5
A nurse is caring for a client who has herpes zoster. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Acyclovir is an antiviral medication that can reduce the severity and duration of herpes zoster symptoms, such as pain, itching, and blisters. Acyclovir can also prevent complications, such as postherpetic neuralgia.
Question 5 of 5
A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?
Correct Answer: C
Rationale: This is because central cyanosis reflects a decrease in arterial oxygen saturation and is best seen in areas where blood vessels are close to the surface, such as the oral mucosa, tongue, and lips. Peripheral cyanosis, which may be caused by vasoconstriction or poor circulation, can be seen in the soles of the feet, ear lobes, and nail beds, but it does not necessarily indicate hypoxemia.