ATI RN
ATI Med Surg Custom N235 Final Summer 2023 Questions
Extract:
Question 1 of 5
A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?
Correct Answer: B
Rationale: A GCS of 13 (3+5+5) indicates the client can follow commands (motor score 5), ruling out unconsciousness.
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 in the emergency department is caring for a client following an automobile crash in which the client was unrestrained and thrown from the vehicle. When assessing the client, the nurse observes clear fluid draining from the client's nose. Which of the following interventions should the nurse take?
Correct Answer: A
Rationale: Clear nasal drainage may be CSF; allowing it to drip onto gauze avoids contamination.
Question 4 of 5
A nurse is monitoring the pulmonary artery wedge pressure (PAWP) for a client. The nurse should identify that a reading of 17 mm Hg is an indication of which of the following conditions?
Correct Answer: C
Rationale: A PAWP of 17 mm Hg (elevated) suggests increased left atrial pressure, commonly due to mitral regurgitation.
Question 5 of 5
A nurse is caring for a client10 client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client?
Correct Answer: A
Rationale: Packed RBCs are used to restore blood volume and oxygen-carrying capacity in hypovolemic shock.