ATI RN
ATI 410 Med Surg Exam Questions
Extract:
Question 1 of 5
A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first?
Correct Answer: B
Rationale: Covering the wound with a moist, sterile dressing is the priority to protect it from infection and manage drainage, preventing further contamination and supporting healing.
Extract:
Nurse's Notes:
Client admitted to the unit for a lower GI bleed. Continues to have frequent bloody stools and is scheduled for a lower endoscopy in 4 hr. The client is receiving their fourth unit of packed red blood cells (packed RBCs). Unit of fourth packed RBCs started at a rate of 250 cc/hr. Thirty minutes after the transfusion started, the client started reporting dyspnea and restlessness. Crackles auscultated in bilateral lower lobes. oxygen saturation 92% on 2L nasal cannula, and jugular vein distention noted.
Vital signs:
Temperature: 37.0°C (98.6°F)
Heart Rate (HR): 110 beats per minute
Blood Pressure (BP): 150/90 mmHg
Respiratory Rate (RR): 24 breaths per minute
Oxygen Saturation (SpO2): 92% on 2L nasal cannula
Question 2 of 5
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
Correct Answer: B,C,D
Rationale: The client is experiencing transfusion-associated circulatory overload (TACO), indicated by dyspnea, crackles, jugular vein distention, and hypertension. Stopping the transfusion prevents further fluid overload, and furosemide removes excess fluid. Monitoring weight and respiratory rate assesses fluid status and respiratory distress.
Extract:
Question 3 of 5
A nurse is teaching a group of clients about the specific types of fluids that protect the structures of the inner ear. Which of the following statements should the nurse include in the teaching?
Correct Answer: A
Rationale: Endolymph is found within the inner ear, specifically in the membranous labyrinth, and plays a crucial role in hearing and balance. Sanguineous fluid refers to blood or fluid containing blood and is not present in the inner ear. Aqueous humor and vitreous humor are fluids found in the eye, not the ear.
Question 4 of 5
A nurse is obtaining a health history from a client who has iron deficiency anemia. Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: Fatigue is a hallmark symptom of iron deficiency anemia due to decreased oxygen-carrying capacity of the blood, leading to tiredness and lack of energy. Slurred speech, confusion, and pain are not typical symptoms unless associated with severe or advanced stages.
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.