ATI RN
ATI 410 Med Surg Exam Questions
Extract:
Question 1 of 5
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)
Correct Answer: A,C,E
Rationale: Tachycardia occurs as the heart compensates for increased blood volume. Hypertension results from increased vascular resistance due to excess fluid. Increased respiratory rate is due to pulmonary congestion from fluid overload. Hematocrit decreases due to dilution, and temperature is not directly affected.
Question 2 of 5
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)
Correct Answer: A,C,E
Rationale: Tachycardia occurs as the heart compensates for increased blood volume. Hypertension results from increased vascular resistance due to excess fluid. Increased respiratory rate is due to pulmonary congestion from fluid overload. Hematocrit decreases due to dilution, and temperature is not directly affected.
Question 3 of 5
After radiation treatment, a client reports dryness, redness, and scaling of his skin occurring within the designated radiation treatment markings. The nurse should instruct the client to take which of the following actions?
Correct Answer: D
Rationale: Hydrating lotions soothe and moisturize skin, alleviating dryness and scaling from radiation. Other options risk further irritation or damage.
Question 4 of 5
A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate?
Correct Answer: B,E
Rationale: Using pillows to elevate heels and minimizing moisture exposure prevent pressure ulcers and skin breakdown. Massaging erythematous areas, 4-hour turning, and powder use increase skin breakdown risk.
Question 5 of 5
A nurse remains with a client to observe for any adverse reactions after initiating a transfusion of packed RBCs. The client becomes apprehensive and tachycardic, reporting headache and low back pain. The nurse should recognize that these findings indicate which of the following transfusion reactions?
Correct Answer: A
Rationale: Acute hemolytic reactions present with fever, chills, headache, low back pain, tachycardia, and apprehension due to red blood cell destruction, requiring immediate intervention.