ATI RN
ATI Med Surg Exam 9 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is postoperative from glaucoma surgery in the right eye. Which of the following will the nurse include in the postoperative education to the client? (Select all that apply)
Correct Answer: C,E,F
Rationale: These instructions ensure proper recovery by monitoring for complications, avoiding activities that increase intraocular pressure, and reassuring about normal post-surgical phenomena.
Question 2 of 5
A nurse is preparing to start an IV infusion of Lactated Ringer's for a client who sustained a burn injury. The client is prescribed 5,200 mL of fluid over the first 24 hr. How many milliliters of fluid will the client receive in the first 8 hours? Record your answer.
Correct Answer: 1733
Rationale: The client receives 1,733 mL in the first 8 hours, calculated as (5,200 mL / 24 hr) × 8 hr = 216.67 mL/hr × 8 = 1,733.33 mL, rounded to 1,733 mL.
Question 3 of 5
A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.)
Correct Answer: B,E,F
Rationale: Bradycardia with bounding pulse, nonreactive dilated pupils, and hypotension with decreasing pulse pressure are late signs of ICP, associated with Cushing's triad and severe neurological compromise.
Question 4 of 5
A client arrives to the emergency department after falling from a ladder. The client has a loss of sensation and flaccid paralysis. Which of the following complications of an acute spinal cord injury does the nurse suspect?
Correct Answer: B
Rationale: Reason: Hemorrhage is not a complication of an acute spinal cord injury, but rather a possible cause of it. Hemorrhage can occur due to trauma or rupture of blood vessels in or around the spinal cord, leading to compression and damage of the nerve tissue. Reason: This is the correct choice. Spinal shock is a complication of an acute spinal cord injury that occurs within minutes to hours after the injury. It is characterized by loss of sensation, motor function, reflexes, and autonomic function below the level of injury. It is caused by transient disruption of nerve conduction and synaptic transmission in the spinal cord. Reason: Apoptosis is not a complication of an acute spinal cord injury, but rather a cellular process that occurs after it. Apoptosis is programmed cell death that occurs in response to injury or stress. It can lead to further loss of neurons and glial cells in the spinal cord over time. Reason: Neurogenic shock is a complication of an acute spinal cord injury that occurs within hours to days after the injury. It is characterized by hypotension, bradycardia, and peripheral vasodilation due to loss of sympathetic tone and unopposed parasympathetic activity. It is caused by disruption of autonomic pathways in the spinal cord.
Question 5 of 5
A nurse in the emergency department is caring for a client following an automobile crash in which the client was unrestrained and thrown from the vehicle. When assessing the client, the nurse observes clear fluid draining from the client's nose. Which of the following interventions should the nurse take?
Correct Answer: D
Rationale: Inserting sterile packing into the nares is the safest option to prevent infection if the fluid is cerebrospinal fluid (CSF), indicating a possible basilar skull fracture, while avoiding actions that could introduce bacteria.