ATI RN
ATI Adult Medical Surgical Assessment 2 Questions
Extract:
Question 1 of 5
A triage nurse finds a school-age child lying in the road following a school bus crash with multiple casualties. The child has a respiratory rate of 8/min, is unresponsive to verbal commands, and groans to painful stimuli. The nurse should assign the client which of the following triage tags?
Correct Answer: A
Rationale: A red tag indicates the need for immediate treatment due to life-threatening conditions. The child's low respiratory rate and unresponsiveness require urgent intervention.
Question 2 of 5
A nurse is caring for a client who has a peripherally inserted central catheter (PICC). For which of the following findings should the nurse notify the provider?
Correct Answer: B
Rationale: An increase in the circumference of the client's upper arm by 10% can indicate swelling, which may be a sign of complications such as infection, thrombosis, or infiltration. This finding should be promptly reported to the provider for further evaluation and intervention.
Question 3 of 5
A nurse is caring for a client who is postoperative and reports frequent leakage of small amounts of urine. The nurse notes that the client's bladder is palpable upon examination. The nurse should identify these findings as which of the following forms of incontinence?
Correct Answer: D
Rationale: Overflow incontinence is characterized by frequent leakage of small amounts of urine due to an overfilled bladder that cannot empty completely. A palpable bladder indicates retention, consistent with overflow incontinence.
Question 4 of 5
A nurse is caring for a client who is using a ventilator when the low-pressure ventilator alarm sounds. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: A low-pressure alarm typically indicates a disconnection or leak, so checking tubing connections is the first step to ensure proper ventilation.
Question 5 of 5
A nurse is providing teaching to a client who is scheduled for a bone marrow biopsy taken from the iliac crest. Which of the following information should the nurse include?
Correct Answer: D
Rationale: Acetaminophen is recommended for post-biopsy pain relief, effective with minimal bleeding risk compared to NSAIDs.