ATI RN
ATI RN Med Surg Custom Exam 2 Questions
Extract:
Question 1 of 5
A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect?
Correct Answer: A,C,D,E
Rationale: A distended bladder is a common sign of urinary retention, which can occur with prostatic hypertrophy. Feeling pressure is a common symptom of urinary retention. Voiding small amounts frequently can be a sign of urinary retention. Tenderness over the symphysis pubis can be a sign of a distended bladder.
Question 2 of 5
A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns on the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention.
Correct Answer: B
Rationale: Airway obstruction is the immediate life-threatening issue due to swelling from burns in the head, neck, and chest area.
Question 3 of 5
A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?
Correct Answer: A
Rationale: A decrease in heart rate is an indication of adequate fluid replacement. As fluid volume is restored, the heart does not have to work as hard to pump blood, so the heart rate decreases.
Question 4 of 5
A nurse is caring for a client and identifies an infiltration at the IV catheter site. Identify the order the nurse should perform the following actions.
Correct Answer: C,A,E,B,D
Rationale: Here's the correct order of actions for managing an IV infiltration: C. Stop the infusion. (This is the priority action to prevent further infiltration.) A. Remove the IV catheter. (Once the infusion is stopped, the source of the infiltration needs to be removed.) E. Elevate the extremity. (This helps reduce swelling.) B. Apply warm or cold compresses. (This helps reduce discomfort and swelling. Warm compresses are generally used for non-vesicant solutions, while cold compresses are used for vesicant solutions, or as ordered. The type of fluid infiltrated is important to know.) D. Apply a sterile dressing. (This protects the insertion site and prevents infection.)
Question 5 of 5
A nurse is providing nail care for a client. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Filing the nails in a rounded shape can prevent injury and is the recommended method for nail care.