ATI Med Surg Custom N235 Final Summer 2023 | Nurselytic

Questions 70

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ATI Med Surg Custom N235 Final Summer 2023 Questions

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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 trailing zero.)

Correct Answer: 100

Rationale: The answer provided is 100%, implying total body surface area burned per the diagram.

Question 2 of 5

The nurse in a trauma unit has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?

Correct Answer: A

Rationale: Evaluating chest expansion assesses breathing, a priority in trauma care per the ABCs.

Question 3 of 5

A nurse is reviewing the PT, aPTT, and INR laboratory values for a client who is experiencing an acute episode of disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect?

Correct Answer: B

Rationale: In DIC, PT, aPTT, and INR are prolonged due to consumption of clotting factors.

Question 4 of 5

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

Correct Answer: D

Rationale: Tracheal deviation to the unaffected side indicates tension pneumothorax, a medical emergency.

Question 5 of 5

A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood gases are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority nursing intervention?

Correct Answer: B

Rationale: Low PaO2 (60 mm Hg) and SaO2 (86%) indicate hypoxemia; oxygen administration is the priority.

Similar Questions

A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances?
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?
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?
A nurse is preparing to administer medications to four clients. The nurse should administer medications to which of the following clients first?
A nurse is caring for a client who had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first?

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