ATI RN
ATI Med Surg Nursing 300 Final Exam Questions
Extract:
Question 1 of 5
A patient presents to the Emergency Department (ED) reporting right facial weakness. The nurse understands that a patient suffering from Bell's Palsy will exhibit which assessment findings related to the cranial nerve involvement?
Correct Answer: C
Rationale: Bell's Palsy causes unilateral facial weakness, including the forehead, due to facial nerve (CN VII) dysfunction, distinguishing it from stroke.
Question 2 of 5
The nurse notices a yellow stain around fluid dripping from a patient's ear who sustained a traumatic brain injury. The nurse's priority intervention will be as follows:
Correct Answer: C
Rationale: Yellow-stained fluid suggests cerebrospinal fluid leak, a TBI complication. Allowing drainage prevents pressure buildup, and notifying the provider ensures further evaluation. Pressure dressings or antibiotics are premature, and IV fluids are unrelated.
Question 3 of 5
The nurse is caring for a patient with wheezes, shortness of breath, urticaria and itching after receiving a new antibiotic The nurse understands that the epilepsy in this situation would be administered intramuscularly (IM), rather than intravenously (IV) because:
Correct Answer: B
Rationale: IM epinephrine is preferred in anaphylaxis to avoid rapid systemic effects of IV administration, which is reserved for cardiac arrest or severe shock.
Question 4 of 5
A client who is postoperative following a coronary artery bypass graft (CABG) has a blood pressure of 90/50 mmHg, heart rate of 112 beats/min, respiratory rate of 28 breaths/min, and an oxygen saturation of 90% on 2L of oxygen via nasal cannula. Which action should the nurse take first?
Correct Answer: A
Rationale: Low oxygen saturation (90%) indicates hypoxemia, a priority. Increasing oxygen to 4L addresses this immediately, before fluids, notification, or positioning.
Question 5 of 5
The nurse is caring for a client who is receiving mechanical ventilation. Which action should the nurse take to prevent ventilator-associated pneumonia?
Correct Answer: B
Rationale: Regular oral care reduces oral bacteria, decreasing the risk of ventilator-associated pneumonia.