ATI RN
ATI Nur258 Med Surg 2 Final Exam Questions
Extract:
Question 1 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 tralling zero. Only enter numbers and decimals. Do not enter any letters in your answer.)
Correct Answer: 31.5
Rationale:
Total = 18+9+4.5= 31.5%
Question 2 of 5
A client with acute lymphocytic leukemia received induction chemotherapy. The client's absolute neutrophil count is zero, and the client is experiencing fatigue and mild nausea. Which nursing action is the highest priority?
Correct Answer: B
Rationale: Limiting contact with infected visitors and placing the client in positive pressure isolation is crucial for preventing infections. With a neutrophil count of zero, the client is highly immunocompromised and at a significant risk of infection, making this the highest priority action.
Question 3 of 5
A nurse is teaching a female client with systemic lupus erythematosus (SLE) about exacerbating factors for their disease. Which statement about exacerbating factors by the client requires further teaching?
Correct Answer: A
Rationale: The statement about keeping the temperature cold to avoid becoming overheated requires further teaching. While avoiding excessive heat is important, maintaining an overly cold environment can also trigger symptoms, such as Raynaud's phenomenon, which is common in SLE patients. Proper temperature regulation, rather than extremes, is essential.
Question 4 of 5
The nurse is assessing a client with a new diagnosis of multiple sclerosis. Which manifestations would the nurse expect to see that are common early signs of multiple sclerosis?
Correct Answer: C
Rationale: Early signs of multiple sclerosis often include areas of numbness, weakness in the legs, and visual problems such as optic neuritis. These symptoms result from demyelination and nerve damage in the central nervous system.
Question 5 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: B
Rationale: The depth of the burn is the primary factor in assessing burn severity. It determines the level of tissue damage and guides treatment decisions. Depth classifications include superficial, partial-thickness, and full-thickness burns.