ATI RN
ATI Nur258 Med Surg 2 Final Exam Questions
Extract:
Question 1 of 5
A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?
Correct Answer: B
Rationale: The depth of the burn is the primary factor in assessing burn severity. It determines the level of tissue damage and guides treatment decisions. Depth classifications include superficial, partial-thickness, and full-thickness burns.
Question 2 of 5
A client arrives in the emergency department with an ischemic stroke. What is the priority for the nurse to assess in relation to the administration of tissue plasminogen activator (t-PA) as treatment?
Correct Answer: A
Rationale: Assessing current anticoagulant use is a priority because t-PA (tissue plasminogen activator) can increase the risk of bleeding, especially if the client has been on anticoagulant medications. It is crucial to determine if there are any contraindications or increased risks for bleeding.
Question 3 of 5
A nurse in a clinic is caring for a female client who was exposed to gonorrhea. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Obtaining information about the client's recent sexual experiences is crucial for assessing risk factors, guiding testing, and determining appropriate treatment for gonorrhea.
Question 4 of 5
The nurse is caring for a client in neurogenic shock following an overdose of anti-anxiety medication. When assessing this client, the nurse should recognize what characteristic of neurogenic shock?
Correct Answer: D
Rationale: Bradycardia is a hallmark of neurogenic shock due to unopposed parasympathetic stimulation resulting from the loss of sympathetic nervous system control.
Question 5 of 5
A nurse is working with a limited staff because of a severe storm in the area. The facility incident commander has initiated disaster protocols. Which of the following actions should the nurse take first?
Correct Answer: B
Rationale: In a disaster situation, prioritizing care for clients with life-threatening emergencies is crucial to ensure that those in the most critical condition receive immediate attention. This aligns with triage principles and ensures that limited resources are used effectively.