ATI RN
ATI RN Adult Medical Surgical 2019 with NGN Questions
Extract:
Question 1 of 5
A nurse is planning care for a client who has Clostridium difficile gastroenteritis. Which of the following is an appropriate nursing action?
Correct Answer: A
Rationale: Clostridium difficile is highly contagious and requires a protective environment to prevent spread. Chlorhexidine and alcohol-based hand rubs are not effective against its spores, and while gloves are used, a protective environment is the priority.
Question 2 of 5
A nurse is caring for a client who has a severe burn injury. The nurse should recognize which of the following client findings as an indication of hypovolemic shock?
Correct Answer: B
Rationale: Hyperkalemia (5.2 mEq/L) from cell destruction in burns indicates hypovolemic shock, risking cardiac complications. Normal urine output, capillary refill, and PaCO2 are not specific to shock.
Question 3 of 5
A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: Chills, back pain, and nausea suggest a hemolytic transfusion reaction; stopping the infusion prevents further exposure to incompatible blood.
Question 4 of 5
A nurse is reviewing a client's cardiac monitor for dysrhythmias. Which of the following findings should the nurse identify as an indication for the placement of a permanent pacemaker?
Correct Answer: B
Rationale: Complete AV block with rates below 40/min risks severe bradycardia and symptoms, necessitating a pacemaker. Other conditions are less severe or not indications.
Question 5 of 5
A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)?
Correct Answer: C
Rationale: The vestibulocochlear nerve (VIII) controls balance and hearing; impaired function causes disequilibrium.
Tongue deviation, vision loss, and inability to smell relate to other cranial nerves.