ATI RN
ATI 410 Med Surg Exam Questions
Extract:
Question 1 of 5
A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions is the nurse's priority?
Correct Answer: B
Rationale: Chills and back pain suggest a serious transfusion reaction, like hemolytic reaction. Stopping the transfusion immediately is the priority to prevent further complications.
Question 2 of 5
A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate?
Correct Answer: B,E
Rationale: Using pillows to elevate heels and minimizing moisture exposure prevent pressure ulcers and skin breakdown. Massaging erythematous areas, 4-hour turning, and powder use increase skin breakdown risk.
Question 3 of 5
A nurse educator is working with the staff to decrease skin tissue injuries to clients on the medical surgical unit. Which of the following practices will decrease friction injuries?
Correct Answer: B
Rationale: Using a trapeze reduces friction and shear forces during repositioning, preventing skin injuries. Other options increase friction or shear risks.
Question 4 of 5
A nurse is caring for a postoperative client following abdominal surgery. Which of the following findings should cause the nurse to anticipate the client might be experiencing a hemorrhage?
Correct Answer: A
Rationale: Hypotension and tachypnea are signs of hemorrhage due to decreased blood volume and compensatory increased respiratory rate. Diaphoresis may occur but is less specific, while bradycardia and diarrhea are not typical.
Question 5 of 5
A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions is the nurse's priority?
Correct Answer: B
Rationale: Chills and back pain suggest a serious transfusion reaction, like hemolytic reaction. Stopping the transfusion immediately is the priority to prevent further complications.