ATI RN
ATI Med Surg Custom N235 Final Summer 2023 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: Elevating the head (high-Fowler's) is the first step to lower BP in autonomic dysreflexia.
Question 2 of 5
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.)
Correct Answer: A,C,E
Rationale: Verifying settings prevents errors, pantoprazole prevents ulcers, and elevating the head reduces aspiration risk.
Question 3 of 5
A nurse is preparing to administer blood to a client. The unit of blood on hand is type B, and the client has type AB blood. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Type AB clients can safely receive type B blood because AB has no antibodies against B antigens, making administration appropriate.
Question 4 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 5 of 5
A nurse in a critical care unit is caring for a client who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?
Correct Answer: D
Rationale: Muffled heart sounds are a classic sign of cardiac tamponade due to pericardial fluid accumulation.