Questions 96

ATI RN

ATI RN Test Bank

ATI Adult Medical Surgical 2019 Questions

Extract:


Question 1 of 5

A nurse is monitoring a client who is receiving 2 units of packed RBCs. Which of the following manifestations indicates a hemolytic transfusion reaction?

Correct Answer: A

Rationale: Back pain is a specific early sign of a hemolytic transfusion reaction due to immune-mediated destruction of transfused RBCs. Bradycardia, hypertension, and chills are less specific.

Question 2 of 5

A nurse in an emergency department is reviewing a client's ECG reading. Which of the following findings should the nurse identify as an indication that the client has first-degree heart block?

Correct Answer: A

Rationale: First-degree heart block is characterized by prolonged PR intervals (>0.20 seconds) due to delayed AV node conduction. Nondiscernible P waves, more P waves than QRS, or no P-QRS correlation indicate other arrhythmias.

Question 3 of 5

A nurse suspects that a client who has diabetes mellitus is experiencing hypoglycemia. Which of the following assessment findings supports this suspicion?

Correct Answer: A

Rationale: Cool, clammy skin is a classic sign of hypoglycemia due to sympathetic nervous system activation. Acetone breath, Kussmaul respirations, and increased urine output are associated with hyperglycemia.

Question 4 of 5

A nurse is caring for a client who is 6 hours postoperative following the application of an external fixator for a tibial fracture. Which of the following actions should the nurse take?

Correct Answer: D

Rationale: Palpating the dorsalis pedis pulse assesses for neurovascular complications, a priority post-fixator application. Wrapping pins, adjusting clamps, or keeping the limb dependent are not standard or safe actions.

Question 5 of 5

A nurse is caring for a client who has hypotension, cool and clammy skin, tachycardia, and tachypnea. In which of the following positions should the nurse place the client?

Correct Answer: C

Rationale: Elevating the feet improves blood flow to vital organs in hypovolemic shock. High-Fowler's, side-lying, and Reverse Trendelenburg do not address hypotension effectively.

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