ATI RN
ATI RN Custom Nursing 221 Exam 4 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?
Correct Answer: A
Rationale: Restlessness is an early sign of increased ICP due to brain pressure.
Question 2 of 5
A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative. Which of the following surgical procedures places the client at risk for deep-vein thrombosis?
Correct Answer: D
Rationale: Hip arthroplasty increases DVT risk due to prolonged immobility.
Question 3 of 5
A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level?
Correct Answer: A
Rationale: Behavioral indicators are the most reliable way to assess pain in a client with expressive aphasia as they may not be able to verbally communicate their pain.
Question 4 of 5
A nurse is caring for a client who has nephrotic syndrome and is receiving high-dose corticosteroid therapy. For which of the following electrolyte imbalances should the nurse monitor?
Correct Answer: A
Rationale: Corticosteroids promote potassium excretion, leading to hypokalemia.
Question 5 of 5
A nurse is reviewing a client's laboratory results and finds the hemoglobin is 10 g/dL and the hematocrit is 30%. The nurse recognizes that the client is at risk for which of the following?
Correct Answer: A
Rationale: Low hemoglobin and hematocrit reduce oxygen delivery, causing cellular hypoxia.