ATI RN
ATI Med Surg Nursing 300 Final Exam Questions
Extract:
Question 1 of 5
After sustaining a serious brain injury, the patient has recovered enough to be transferred to a rehabilitation unit for continued care. Which statement by the patient indicates that they understand realistic goal setting?
Correct Answer: D
Rationale: Active participation in rehabilitation is a realistic goal, focusing on effort and progress. Expecting full recovery of memories, traits, or functions is unrealistic due to potential permanent brain injury effects.
Question 2 of 5
The nurse is preparing to administer a unit of packed red blood cells (PRBC's) to a patient whose blood type is A- (negative). The nurse knows that this patient can receive transfusions from which blood types? (SELECT ALL THAT APPLY).
Correct Answer: A,D
Rationale: A- patients can receive O- (universal donor) and A- blood, as both lack B and Rh antigens, preventing immune reactions.
Question 3 of 5
The nurse assesses the patient with a spinal cord injury at the level C-7 and finds warm, flushed skin with profuse sweating above the level of injury, and pale, cold skin below the level of injury. The patient is bradycardic, but severely hypertensive. What are the priority nursing interventions?
Correct Answer: B
Rationale: Symptoms indicate autonomic dysreflexia, requiring assessment for noxious stimuli (e.g., bladder distension) and anticipation of antihypertensives to manage severe hypertension.
Question 4 of 5
The nurse easily and quickly assesses changes in level of consciousness (eye opening, verbal responses motor response) using which neurological exams?
Correct Answer: A
Rationale: The Glasgow Coma Scale assesses consciousness via eye, verbal, and motor responses, ideal for rapid neurological evaluation.
Question 5 of 5
The nurse is caring for a patient with an acute head injury. Which assessment finding would first alert the nurse that the patient is developing an increase in intracranial pressure (ICP)?
Correct Answer: C
Rationale: Altered level of consciousness is the earliest sign of increased ICP, reflecting brain compression. Sluggish pupils and widening pulse pressure are later signs, and tachycardia with hypotension is not typical.