ATI RN
ATI Med Surg Custom N235 Final Summer 2023 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: D
Rationale: The location of the burn is the priority because burns to the face and neck can compromise the airway, making it the most immediate threat to life.
Question 2 of 5
A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?
Correct Answer: B
Rationale: A GCS of 13 (3+5+5) indicates the client can follow commands (motor score 5), ruling out unconsciousness.
Question 3 of 5
A nurse in an emergency department is caring for an adult client who has burns on the front and back of both his legs and arms. Using the rule of nines, the nurse should document burns to which percentage of the client's total body surface area (TBSA)?
Correct Answer: A
Rationale: Rule of nines: each arm (18%) + each leg (18%) = 9% × 4 (front and back) = 54% TBSA.
Question 4 of 5
A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances?
Correct Answer: D
Rationale: A pH of 7.3 (low) and PaCO2 of 50 mm Hg (high) indicate respiratory acidosis due to CO2 retention.
Question 5 of 5
A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Tachypnea and hypotension indicate hypoxemia; oxygen administration is the priority.