ATI RN
ATI Adult Medical Surgical Assessment 2 Questions
Extract:
Question 1 of 5
A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following findings should the nurse report to the provider immediately?
Correct Answer: B
Rationale: Decreasing voice volume can indicate cranial nerve involvement and potential respiratory muscle weakness, which can lead to respiratory failure. This is an urgent finding requiring immediate attention.
Question 2 of 5
A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and is receiving 3% sodium chloride via continuous IV. Which of the following laboratory findings should the nurse identify as an indication that the SIADH is resolving?
Correct Answer: A
Rationale: A normal urine specific gravity (1.02) indicates appropriate water excretion, suggesting resolving SIADH, as concentrated urine is typical in active SIADH.
Question 3 of 5
A nurse is providing discharge teaching to a client who has acute leukemia and received chemotherapy 12 hours ago. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
Correct Answer: A,B,E
Rationale: Using an electric shaver reduces the risk of bleeding due to low platelet counts post-chemotherapy. Avoiding crowds minimizes infection risk in immunocompromised patients. Monitoring for bruising helps detect bleeding complications early. Taking temperature weekly is insufficient, and a low-residue diet is not typically necessary.
Question 4 of 5
A nurse is caring for a client who has increased intracranial pressure (ICP). Which of the following interventions should the nurse implement?
Correct Answer: C
Rationale: Keeping the neck in a midline position helps ensure proper venous drainage from the brain, reducing intracranial pressure. This is a standard practice in managing patients with elevated ICP.
Question 5 of 5
A nurse is receiving report on a group of clients. Which of the following clients should the nurse assess first?
Correct Answer: B
Rationale: Urticaria and edema after cephalosporin administration suggest a possible allergic reaction, which could progress to anaphylaxis, requiring immediate assessment.