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 extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?
Correct Answer: B
Rationale: Airway obstruction is the priority due to the risk of swelling from burns to the head and neck, which can compromise breathing, aligning with the ABCs of trauma care.
Question 2 of 5
A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?
Correct Answer: D
Rationale: Cranial nerve III (oculomotor) controls pupil constriction, so checking pupillary response to light assesses its function.
Question 3 of 5
A nurse is admitting a client who has sustained severe burn injuries in a grease fire. The nurse shades in a diagram indicating the burned surface areas. Using the Rule of Nines, the nurse should estimate that the client has burned what percentage of body surface area? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 100
Rationale: The answer provided is 100%, implying total body surface area burned per the diagram.
Question 4 of 5
A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?
Correct Answer: B
Rationale: Airway obstruction is the priority due to the risk of swelling from burns to the head and neck, which can compromise breathing, aligning with the ABCs of trauma care.
Question 5 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.