ATI RN
ATI Med Surg Custom N235 Final Summer 2023 Questions
Extract:
Question 1 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 2 of 5
A nurse in the emergency department is caring for a client who has sustained a head injury. The nurse notes the client's IV fluids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse?
Correct Answer: C
Rationale: In head injury, rapid fluid infusion (125 mL/hr) can worsen ICP; slowing to 20 mL/hr is safer.
Question 3 of 5
A nurse is caring for a client who had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first?
Correct Answer: B
Rationale: Checking the oximeter first assesses oxygenation status, which is critical post-surgery and aligns with the priority of ensuring adequate breathing.
Question 4 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 5 of 5
A nurse is caring for a client who has an epidural hematoma. Which of the following manifestations should the nurse expect?
Correct Answer: D
Rationale: Epidural hematomas classically present with a lucid period followed by rapid deterioration.