ATI RN
ATI Adult Medical Surgical Assessment 2 Questions
Extract:
Question 1 of 5
A nurse is receiving report on a group of clients. Which of the following clients should the nurse assess first?
Correct Answer: B
Rationale: Urticaria and edema after cephalosporin administration suggest a possible allergic reaction, which could progress to anaphylaxis, requiring immediate assessment.
Question 2 of 5
A nurse is providing instructions to a newly licensed nurse about NG intubation for a client who is postoperative following a colectomy. Which of the following statements should the nurse include?
Correct Answer: C
Rationale: An NG tube post-colectomy decompresses the stomach, reducing pressure and preventing vomiting to aid gastrointestinal healing.
Question 3 of 5
A nurse is caring for a client who is hyperventilating and has the following ABG results: pH 7.50 (7.35 to 7.45), PaCO₂ 29 mm Hg (35 to 45 mm Hg), and HCO₃ 25 mEq/L (21 to 28 mEq/L). The nurse should identify that the client has which of the following acid-base imbalances?
Correct Answer: B
Rationale: A high pH (7.50) and low PaCO₂ (29 mm Hg) indicate respiratory alkalosis, caused by hyperventilation leading to excessive CO₂ exhalation.
Question 4 of 5
A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should indicate to the nurse the need for immediate intervention?
Correct Answer: C
Rationale: A respiratory rate of 30/min is significantly elevated, indicating potential respiratory distress or neurological deterioration, requiring immediate intervention.
Question 5 of 5
A nurse is preparing to administer epoetin to a client who has anemia due to chemotherapy. Which of the following actions should the nurse plan to take?
Correct Answer: A
Rationale: Monitoring hemoglobin levels before administering epoetin ensures safe and effective treatment, preventing complications like hypertension or thromboembolism if levels are too high.