ATI RN
ATI 410 Med Surg Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect?
Correct Answer: D
Rationale: A hemolytic reaction involves red blood cell destruction, leading to fever, chills, and red-tinged urine due to hemoglobin in the urine, indicating a serious reaction.
Question 2 of 5
A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?
Correct Answer: A
Rationale: A decrease in heart rate indicates improved cardiac output and reduced tachycardia, suggesting adequate fluid replacement. Weight may increase, urine output should increase, and BP stabilizes but is less direct an indicator.
Question 3 of 5
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)
Correct Answer: A,C,E
Rationale: Tachycardia occurs as the heart compensates for increased blood volume. Hypertension results from increased vascular resistance due to excess fluid. Increased respiratory rate is due to pulmonary congestion from fluid overload. Hematocrit decreases due to dilution, and temperature is not directly affected.
Question 4 of 5
A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?
Correct Answer: A
Rationale: Scatter rugs can cause tripping and slipping, posing a significant fall risk for someone with vision impairment. Handrails provide support and help prevent falls, making them a safety feature, not a risk. Electrical cords placed along walls reduce tripping hazards. A microwave is generally safer than a stove, reducing the risk of burns and fires.
Question 5 of 5
A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for clients who have surgical incisions. Which of the following factors should the nurse include in the teaching? (Select all that apply.)
Correct Answer: B,C,D
Rationale: Poor nutrition weakens tissue strength, infection compromises wound integrity, and obesity increases pressure on the wound, all raising dehiscence risk. Pain medication and altered mental status do not directly contribute.