ATI RN
ATI Nur258 Med Surg 2 Final Exam Questions
Extract:
Question 1 of 5
An 82-year-old client who sustained a head injury in a motor vehicle crash while on warfarin therapy is admitted for observation. The nurse is providing teaching regarding the client's diagnosis of a subdural hematoma. Which of the following statements by the client indicates an understanding of teaching?
Correct Answer: C
Rationale: Taking a blood thinner like warfarin increases the risk of bleeding and hematoma formation, particularly when combined with head trauma. This statement correctly links the anticoagulant therapy and head injury as contributing factors to the subdural hematoma.
Question 2 of 5
A client is diagnosed with systemic inflammatory response syndrome (SIRS) as a result of a bacterial infection. Which nursing intervention may prevent the development of multiple-organ dysfunction syndrome (MODS)?
Correct Answer: D
Rationale: Administering antibiotics to treat the bacterial infection and maintaining a mean arterial pressure (MAP) of at least 65 mm Hg are essential interventions. Effective antibiotic therapy addresses the infection, and maintaining MAP ensures adequate organ perfusion, both of which help prevent the progression to MODS.
Question 3 of 5
A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?
Correct Answer: B
Rationale: The depth of the burn is the primary factor in assessing burn severity. It determines the level of tissue damage and guides treatment decisions. Depth classifications include superficial, partial-thickness, and full-thickness burns.
Question 4 of 5
A nurse is caring for a client who has human immunodeficiency virus (HIV). Which of the following laboratory values would be most concerning to the nurse?
Correct Answer: D
Rationale: A WBC count of 800/mm³ is severely low and indicates a high risk for infection, which is particularly concerning in a client with HIV, as it suggests significant immunosuppression and vulnerability to opportunistic infections.
Question 5 of 5
An adult client in the intensive care unit (ICU) with a central venous catheter has developed signs and symptoms that are suggestive of a central line-associated bloodstream infection (CLABSI). What is most likely the cause of the infection?
Correct Answer: C
Rationale: Changing the central line dressing using clean technique instead of sterile technique increases the risk of introducing pathogens to the central line site, leading to a central line-associated bloodstream infection (CLABSI).