ATI RN
ATI Med Surg Custom N235 Final Summer 2023 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has a traumatic brain injury. The nurse notes that the client has a widening pulse pressure. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Widening pulse pressure suggests increased ICP; elevating the head to 30° reduces it.
Question 2 of 5
A nurse is assessing a client in the oliguric phase of acute kidney injury. Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: Hyperkalemia is expected in the oliguric phase of AKI due to reduced potassium excretion.
Question 3 of 5
A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take?
Correct Answer: D
Rationale: Elevating the head (typically 30°, but 20° here) reduces ICP by aiding venous drainage.
Question 4 of 5
A client who is having burn debridement states, 'You are the worst nurse I have ever seen. All you do is hurt me.' Which of the following responses should the nurse make?
Correct Answer: D
Rationale: Tell me more about that' encourages the client to express feelings, promoting therapeutic communication.
Question 5 of 5
A nurse is caring for a client who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select all that apply.)
Correct Answer: A,C,E
Rationale: Verifying settings prevents errors, pantoprazole prevents ulcers, and elevating the head reduces aspiration risk.