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: Placing the client in a high-Fowler's position reduces blood pressure in autonomic dysreflexia by promoting venous pooling.
Question 2 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 3 of 5
A nurse is prioritizing client care after receiving change-of-shift report. Which of the following clients should the nurse plan to see first?
Correct Answer: A
Rationale: Shortness of breath is a potential airway or breathing issue, making it the highest priority per ABCs.
Question 4 of 5
A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO2 is 48 mm Hg and the HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate which of the following acid-base imbalances?
Correct Answer: A
Rationale: pH 7.32 (low), PaCO2 48 mm Hg (high), and normal HCO3 indicate respiratory acidosis from CO2 retention.
Question 5 of 5
A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hr following a burn injury?
Correct Answer: D
Rationale: Lactated Ringer's is the standard fluid for burn resuscitation in the first 24 hours per the Parkland formula.