ATI RN
ATI Med Surg Custom N235 Final Summer 2023 Questions
Extract:
Question 1 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 2 of 5
A nurse in the emergency department is caring for a client following an automobile crash in which the client was unrestrained and thrown from the vehicle. When assessing the client, the nurse observes clear fluid draining from the client's nose. Which of the following interventions should the nurse take?
Correct Answer: A
Rationale: Clear nasal drainage may be CSF; allowing it to drip onto gauze avoids contamination.
Question 3 of 5
A nurse is caring for a client who has acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply.)
Correct Answer: B,D,E
Rationale: Severe dyspnea and hypotension (listed twice) are key signs of ARF due to impaired gas exchange.
Question 4 of 5
A nurse is monitoring the pulmonary artery wedge pressure (PAWP) for a client. The nurse should identify that a reading of 17 mm Hg is an indication of which of the following conditions?
Correct Answer: C
Rationale: A PAWP of 17 mm Hg (elevated) suggests increased left atrial pressure, commonly due to mitral regurgitation.
Question 5 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.