ATI RN
ATI RN Adult Medical Surgical 2019 with NGN Questions
Extract:
Question 1 of 5
A nurse is monitoring a client who is receiving 2 units packed RBCs. Which of the following manifestations indicates a hemolytic transfusion reaction?
Correct Answer: D
Rationale: Back pain is a hallmark of hemolytic transfusion reaction, caused by immune destruction of donor RBCs, requiring immediate intervention.
Question 2 of 5
A nurse is assessing a client who has increased intracranial pressure (ICP). The nurse should recognize that which of the following is the first sign of deteriorating neurological status?
Correct Answer: C
Rationale: Altered level of consciousness is the earliest and most sensitive sign of increased ICP, detectable via the Glasgow Coma Scale. Pupillary dilation, decorticate posturing, and Cheyne-Stokes respirations are later signs indicating severe brainstem involvement.
Question 3 of 5
A nurse is preparing to assist with the insertion of a non-tunneled central venous catheter for a client who is malnourished. Which of the following actions should the nurse plan to take?
Correct Answer: D
Rationale: Confirming catheter position with a blood sample ensures proper placement. Valsalva maneuver, elevated bed, and chlorhexidine cleansing are appropriate, not coughing, lowering bed, or hydrogen peroxide.
Question 4 of 5
A nurse is reviewing the medical record of a client who is 1 day postoperative following an appendectomy. Which of the following findings should the nurse report to the provider?
Correct Answer: D
Rationale: A hemoglobin of 10 mg/dL suggests blood loss, requiring immediate reporting. Normal WBC, mild pain, and serosanguineous exudate are expected post-appendectomy.
Question 5 of 5
A home health nurse is assessing the home environment of a client who has cystic fibrosis. Which of the following equipment should the nurse plan to recommend?
Correct Answer: B
Rationale: A chest physiotherapy vest loosens mucus in cystic fibrosis, improving lung function. Peak flow meters are for asthma, NG tubes for gastric issues, and chest tubes for pleural conditions.