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 has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering?
Correct Answer: B
Rationale: Heparin is the anticoagulant of choice to prevent further clot formation in pulmonary embolism.
Question 3 of 5
A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority?
Correct Answer: B
Rationale: Suctioning saliva prevents airway obstruction, a priority in an unconscious client.
Question 4 of 5
A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The client reports dyspnea and severe pain. The nurse notes that the client's chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following?
Correct Answer: C
Rationale: Paradoxical chest movement (inward on inspiration, outward on expiration) is characteristic of flail chest.
Question 5 of 5
A nurse is reviewing the arterial blood gas results for a client in the ICU who has kidney failure and determines the client has respiratory acidosis. Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: Widened QRS complexes can occur in respiratory acidosis due to hyperkalemia from kidney failure.