ATI RN
ATI Med Surg 2 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: C
Rationale: This is correct because the client's GCS score is 13, which indicates a severe impairment of consciousness. A GCS score of 8 or less indicates coma, but 13 still suggests significant impairment.
Question 2 of 5
A nurse is helping to triage a group of clients at a mass casualty incident who were involved in an explosion at a local factory. Which of the following clients should the nurse tag to be the priority for care?
Correct Answer: D
Rationale: This is correct because this client has a life-threatening condition called tension pneumothorax, which requires immediate care. The hissing sound indicates air escaping from the lung, necessitating urgent intervention.
Question 3 of 5
A nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction. Which of the following prescriptions should the nurse take first?
Correct Answer: B
Rationale: Initiating oxygen therapy ensures adequate oxygenation to prevent further myocardial damage.
Question 4 of 5
A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse that the client is developing this condition?
Correct Answer: D
Rationale: Breathlessness is a manifestation of left-sided heart failure, caused by pulmonary congestion and edema impairing gas exchange.
Question 5 of 5
A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level?
Correct Answer: C
Rationale: A self-report pain rating scale is the most valid method to assess pain, even with expressive aphasia, using simple scales.