ATI RN
ATI Med Surg 2 Questions
Extract:
Question 1 of 5
A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the following findings as an indication of hypovolemic shock?
Correct Answer: B
Rationale: Increased heart rate is a sign of hypovolemic shock as the body compensates for decreased blood volume.
Question 2 of 5
A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level?
Correct Answer: C
Rationale: A self-report pain rating scale is the most valid method to assess pain, even with expressive aphasia, using simple scales.
Question 3 of 5
A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the following findings as an indication of hypovolemic shock?
Correct Answer: B
Rationale: Increased heart rate is a sign of hypovolemic shock as the body compensates for decreased blood volume.
Question 4 of 5
A nurse is helping to triage a group of clients at a mass casualty incident who were involved in an explosion at a local factory. Which of the following clients should the nurse tag to be the priority for care?
Correct Answer: D
Rationale: This is correct because this client has a life-threatening condition called tension pneumothorax, which requires immediate care. The hissing sound indicates air escaping from the lung, necessitating urgent intervention.
Question 5 of 5
A nurse is triaging victims of a multiple motor-vehicle crash. The nurse assesses a client trapped under a car who is apneic and has a weak pulse at 120/min. After repositioning his upper airway, the client remains apneic. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: In mass casualty triage, an apneic client who does not resume breathing after airway repositioning is tagged black, indicating non-salvageable status.