ATI RN
ATI Med Surg Exam 9 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider?
Correct Answer: D
Rationale: Reason: A heart rate of 122/min is elevated, but not life-threatening. It could be due to pain, anxiety, dehydration, or infection. Reason: A urinary output of 25 ml/hr is low, but not critical. It could indicate fluid loss, kidney damage, or inadequate fluid resuscitation. Reason: A pain level of 6 on a scale of 0 to 10 is moderate, but not severe. It could be managed with analgesics and non-pharmacological interventions. Reason: This is the correct answer because difficulty swallowing can indicate airway obstruction, inhalation injury, or edema of the throat. It can compromise breathing and require immediate intervention.
Question 2 of 5
A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.)
Correct Answer: B,E,F
Rationale: Bradycardia with bounding pulse, nonreactive dilated pupils, and hypotension with decreasing pulse pressure are late signs of ICP, associated with Cushing's triad and severe neurological compromise.
Question 3 of 5
A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client?
Correct Answer: B,E,F
Rationale: Administering oxygen helps prevent hypoxia due to potential airway damage. Assessing the airway is critical to detect swelling or inhalation injury. Applying ice reduces pain and swelling but must be used cautiously to avoid tissue damage.
Question 4 of 5
A nurse caring for a client with acute peritonitis reviews the physician's orders. The orders include an NPO diet, insertion of a nasogastric tube set to low intermittent suction, and IV fluids at 50 mL per hour. When asked why he will need the NG tube, what is the nurse's best reply?
Correct Answer: D
Rationale:
To administer medications and electrolytes is not the best reply for why the client will need the NG tube, because this is not the primary purpose of the NG tube in this case. The NG tube is mainly used to relieve gastric distension and prevent vomiting and aspiration. Medications and electrolytes can be given through the IV route.
To dilate the stomach as a presurgical preparation is not the best reply for why the client will need the NG tube, because this is not a valid indication for the NG tube in this case. The NG tube is mainly used to relieve gastric distension and prevent vomiting and aspiration. Dilation of the stomach is not a goal of presurgical preparation, but rather an adverse effect of gastric obstruction. You will not be able to eat for several days is not the best reply for why the client will need the NG tube, because this is not a complete or accurate explanation of the NG tube in this case. The NG tube is mainly used to relieve gastric distension and prevent vomiting and aspiration. The client will not be able to eat for several days because of the NPO diet, which is necessary to rest the inflamed peritoneum and reduce the risk of complications.
To remove secretions and decompress your stomach is the best reply for why the client will need the NG tube, because this is a clear and correct explanation of the NG tube in this case. The NG tube is mainly used to relieve gastric distension and prevent vomiting and aspiration, which are common symptoms of acute peritonitis. By removing secretions and decompressing the stomach, the NG tube can reduce pain, inflammation, and infection in the abdominal cavity.
Question 5 of 5
A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. The nurse should identify which of the following risks as the priority for assessment and intervention?
Correct Answer: A
Rationale: Airway obstruction is the priority due to potential edema, inflammation, or inhalation injury in burns of the head, neck, and chest, which can compromise oxygenation and lead to respiratory failure.