ATI RN
ATI Medsurg Proctored Final Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability?
Correct Answer: A
Rationale: The correct answer is A: Paraplegia. Damage at the T2-T3 vertebrae level affects the lower part of the body, resulting in paralysis of the legs and potentially part of the trunk (paraplegia). This injury does not affect the arms or hands, ruling out tetraplegia (
B) and quadriplegia (
C). Hemiplegia (
D) refers to paralysis on one side of the body only, which is not the case here. Other choices are not applicable.
Question 2 of 5
A nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Decreased serum calcium level. In fat embolism syndrome (FES), fat droplets enter the bloodstream and can affect various organs. One of the common complications is hypocalcemia due to the binding of calcium to the fatty acids, leading to decreased serum calcium levels. This can result in symptoms such as confusion, tetany, and seizures. The other choices are incorrect because: B: Increased potassium level is not typically associated with FES. C: Decreased white blood cell count is not a common finding in FES. D: Increased serum albumin level is not related to FES.
Question 3 of 5
A nurse is caring for a client with a sucking chest wound from a gunshot. What action should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen via nasal cannula. This is the priority action to ensure the client receives adequate oxygenation. In a sucking chest wound, air enters the pleural space, leading to a potential pneumothorax, which can compromise oxygenation. Administering oxygen helps maintain oxygen saturation levels and supports respiratory function. Placing the client in Trendelenburg position (choice
B) can worsen respiratory distress by increasing pressure on the diaphragm. Applying a warm compress (choice
C) may promote bleeding and is not effective in managing a sucking chest wound. Encouraging deep breathing exercises (choice
D) can further exacerbate the pneumothorax by allowing more air to enter the pleural space.
Question 4 of 5
A nurse is assessing a client's wound dressing and observes a watery red drainage. The nurse should document this drainage as which of the following?
Correct Answer: C
Rationale: The correct answer is C: Serosanguineous. This type of drainage is a mixture of clear (serous) and red (sanguineous) fluids, indicating a normal stage of wound healing. The clear fluid suggests minimal inflammation, while the red fluid indicates presence of blood. Serous drainage alone is typically clear and watery without any blood. Sanguineous drainage is bright red and indicates fresh blood. Purulent drainage is thick, opaque, and yellowish-green, suggestive of infection.
Therefore, in this scenario, the observation of watery red drainage best fits the description of serosanguineous drainage.
Question 5 of 5
A nurse is caring for a postoperative client. Which procedure places the client at highest risk for DVT?
Correct Answer: B
Rationale: The correct answer is B: Hip arthroplasty. This procedure involves prolonged immobility, causing blood stasis and increasing the risk of deep vein thrombosis (DVT). The reduced blood flow in the legs can lead to clot formation. Appendectomy (
A), cholecystectomy (
C), and tonsillectomy (
D) are not typically associated with prolonged immobility like hip arthroplasty, thus lower DVT risk.