ATI RN
ATI Med Surg 2 Questions
Extract:
Question 1 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: B
Rationale: Elevating the head of the bed to 30 degrees reduces intracranial pressure by facilitating venous drainage.
Question 2 of 5
A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse that the client is developing this condition?
Correct Answer: D
Rationale: Breathlessness is a manifestation of left-sided heart failure, caused by pulmonary congestion and edema impairing gas exchange.
Question 3 of 5
A nurse in the emergency department is caring for a client who 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: Continuing at 125 mL/hr maintains hydration without risking fluid overload or increased intracranial pressure.
Question 4 of 5
A nurse is helping to triage a group of clients at a mass casualty incident who were involved in an explosion at a local factory. Which of the following clients should the nurse tag to be the priority for care?
Correct Answer: D
Rationale: This is correct because this client has a life-threatening condition called tension pneumothorax, which requires immediate care. The hissing sound indicates air escaping from the lung, necessitating urgent intervention.
Question 5 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: B
Rationale: Elevating the head of the bed to 30 degrees reduces intracranial pressure by facilitating venous drainage.