ATI RN
ATI Med Surg Custom N235 Final Summer 2023 Questions
Extract:
Question 1 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.
Question 2 of 5
A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: Placing the client in a high-Fowler's position reduces blood pressure in autonomic dysreflexia by promoting venous pooling.
Question 3 of 5
A nurse is caring for a client who has a deep vein thrombosis and is prescribed heparin by continuous IV infusion at 1,200 units/hr. Available is heparin 25,000 units in 500 mL D5W. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 24
Rationale: Calculation: (1,200 units/hr ÷ 25,000 units) × 500 mL = 24 mL/hr, ensuring the correct heparin dose is delivered.
Question 4 of 5
A nurse in the emergency department is caring for a client who has an epidural hematoma following a motor-vehicle crash. Which of the following is an expected finding for this client?
Correct Answer: B
Rationale: Epidural hematomas often present with a lucid interval followed by unconsciousness due to rapid bleeding.
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.