ATI Med Surg Custom N235 Final Summer 2023 | Nurselytic

Questions 70

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ATI Med Surg Custom N235 Final Summer 2023 Questions

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Question 1 of 5

A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take?

Correct Answer: A

Rationale: Log rolling maintains spinal alignment and minimizes ICP increases during repositioning.

Question 2 of 5

A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care?

Correct Answer: B

Rationale: In trauma situations, the priority is to ensure a patent airway (airway protection) as per the ABCs (Airway, Breathing, Circulation) of emergency care, since oxygenation is critical for survival.

Question 3 of 5

A nurse is caring for a client who is experiencing Cushing's triad following a subdural hematoma. Which of the following medications should the nurse plan to administer?

Correct Answer: C

Rationale: Mannitol 25% reduces intracranial pressure, addressing the critical components of Cushing's triad.

Question 4 of 5

A nurse is caring for a client who has a pulmonary embolism and has a new prescription for enoxaparin 1.5 mg/kg/dose subcutaneously every 12 hours. The client weighs 245 lbs. How many mg should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer: 167

Rationale: Calculation: 245 lbs ÷ 2.2 = 111.36 kg; 111.36 kg × 1.5 mg/kg = 167 mg, the correct dose.

Question 5 of 5

A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood gases are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority nursing intervention?

Correct Answer: B

Rationale: Low PaO2 (60 mm Hg) and SaO2 (86%) indicate hypoxemia; oxygen administration is the priority.

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A nurse is caring for a client who has acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply.)
A nurse is caring for a client who has a deep vein thrombosis and is prescribed heparin by continuous IV infusion at 1,200 units/hr. Available is heparin 25,000 units in 500 mL D5W. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.)
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.)

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