ATI RN
ATI nur330 Med Surg Exam Questions
Extract:
Question 1 of 5
A nurse is assisting with triaging clients following an explosion. Which of the following clients should the nurse identify as the highest priority?
Correct Answer: B
Rationale: In mass casualty triage, clients with compromised respiration (>30 breaths/min) are prioritized as they may deteriorate quickly. Unconscious clients with absent respirations are considered unsalvageable in triage protocols.
Question 2 of 5
A client is recovering from an open reduction of the femur suddenly feels light headed, with increased anxiety and agitation. Which key vital sign differentiates early sepsis from a pulmonary embolism?
Correct Answer: D
Rationale: Fever is an early sign of sepsis, differentiating it from pulmonary embolism, which is associated with respiratory distress, tachycardia, and chest pain. Tachycardia, hypotension, and tachypnea are present in both.
Question 3 of 5
A nurse is caring for a client who has a seizure disorder. Which of the following actions should the nurse take?
Correct Answer: A,C,E
Rationale: Supplemental oxygen addresses hypoxia, turning the client to the side prevents aspiration, and timing the seizure guides treatment. Inserting a tongue depressor can cause injury, and restraining may harm the client.
Question 4 of 5
A sexual assault nurse examiner (SANE) is a caring for a client who experienced sexual assault. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The SANE's priority is to ensure the client's safety and well-being. Legal testimony, police involvement, and evidence collection are secondary or not the nurse's role.
Question 5 of 5
A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?
Correct Answer: A
Rationale: Muffled heart sounds are a hallmark finding in cardiac tamponade due to fluid accumulation in the pericardial sac, which dampens the sound of the heart. Flattened neck veins are inconsistent with cardiac tamponade; distended neck veins are commonly seen. Tachycardia, not bradycardia, is a compensatory response. Lethargy is not specific to cardiac tamponade.