ATI RN
ATI Med Surg 2 Questions
Extract:
Question 1 of 5
A nurse is triaging victims of a multiple motor-vehicle crash. The nurse assesses a client trapped under a car who is apneic and has a weak pulse at 120/min. After repositioning his upper airway, the client remains apneic. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: In mass casualty triage, an apneic client who does not resume breathing after airway repositioning is tagged black, indicating non-salvageable status.
Question 2 of 5
A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?
Correct Answer: B
Rationale: This is correct because increased respiratory rate is an early sign of shock, indicating hypoxia as a compensatory mechanism.
Question 3 of 5
A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: Elevated CVP is a finding of right-sided heart failure, reflecting increased pressure in the systemic venous system.
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 was admitted with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Providing frequent oral and nares care prevents infection and irritation from the tube.