ATI RN
ATI Med Surg Custom N235 Final Summer 2023 Questions
Extract:
Question 1 of 5
A nurse is caring for a client 4 hr following evacuation of a subdural hematoma. Which of the following assessments is the nurse's priority?
Correct Answer: A
Rationale: Respiratory status is the priority post-surgery per ABCs, as airway compromise can occur.
Question 2 of 5
A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Repositioning the client can alleviate discomfort from the chest tube without risking complications.
Question 3 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 4 of 5
A nurse in the emergency department is caring for a client who has sustained a head injury. The nurse notes the client's IV fluids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse?
Correct Answer: C
Rationale: In head injury, rapid fluid infusion (125 mL/hr) can worsen ICP; slowing to 20 mL/hr is safer.
Question 5 of 5
A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2°C (100.8°F). Which of the following neurologic disorders should the nurse suspect?
Correct Answer: D
Rationale: Sudden headache, seizure, and hypertension suggest a hemorrhagic stroke, likely from a ruptured vessel.