ATI RN Adult Medical Surgical 2023 IV

Extract:

Question 1 of 5

A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes that the weights are resting on the floor. Which of the following actions should the nurse take?

A. Remove one of the weights. B. Tie knots in the ropes near the pulleys to shorten them. C. Pull the client up in bed. D. Increase the elevation of the affected extremity.

Correct Answer: C

Rationale: Pulling the client up (
C) restores traction by lifting weights off the floor. Removing weights (
A), tying knots (
B), or elevating further (
D) disrupts traction alignment.

Question 2 of 5

A nurse is assessing a client who has major full-thickness burns to their lower legs 12 hr ago. Which of the following findings should the nurse expect?

A. Blistering at the site B. Severe pain at the site C. Epithelialization at the site D. Edema at the site

Correct Answer: D

Rationale: Edema (
D) is expected 12 hours post-burn due to vascular permeability. Full-thickness burns lack blisters (
A) and pain (
B) due to nerve damage, and epithelialization (
C) occurs later.

Question 3 of 5

A charge nurse receives a call from the house supervisor requesting room assignments for four new clients. Based on the admission diagnoses, which of the following clients requires a private room?

A. A client who has diabetes mellitus and is presenting with acute ketoacidosis B. An older adult client who was admitted with aspiration pneumonia C. A client who has a compound fracture of the right femur D. A client who reports having fever, night sweats, and cough for 2 days

Correct Answer: D

Rationale: Fever, night sweats, and cough (
D) suggest possible TB, requiring airborne isolation in a private room. DKA (
A), pneumonia (
B), and fractures (
C) do not require private rooms.

Question 4 of 5

A nurse in the emergency department is monitoring a client who is receiving dopamine to treat hypovolemic shock. Which of the following findings should the nurse identify as an indication for increasing the client's dopamine dosage?

A. Oxygen saturation 95% B. Respiratory rate 14/min C. Blood pressure 90/50 mm Hg D. Heart rate 60/min

Correct Answer: C

Rationale: Low blood pressure (
C) indicates inadequate perfusion, warranting a dopamine increase. Normal oxygen (
A), respiratory rate (
B), and heart rate (
D) do not require dose adjustment.

Question 5 of 5

A nurse is caring for a client who has a spinal cord injury and has developed autonomic dysreflexia. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Order the Items

Source Container

Confirm that the client's bladder is empty.

Indicate the risk for autonomic dysreflexia in the client's medical record.

Place the client in an upright sitting position.

Administer an antihypertensive medication intravenously.

Correct Answer: C,A,D,B

Rationale: Upright positioning (
C) reduces blood pressure, checking bladder (
A) addresses triggers, antihypertensives (
D) manage hypertension, and documentation (
B) follows treatment.

ATI RN Adult Medical Surgical 2023 IV | Nurselytic

Nurselytic

ATI RN

ATI RN