ATI RN
ATI EW N300 Med Surg Exam Questions
Extract:
Question 1 of 5
The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a patient with an acute head injury. Which actions should the nurse take to achieve this goal?
Correct Answer: A,B,D
Rationale: Elevating the head of the bed aids venous drainage, serial assessments monitor ICP changes, and sedatives/pain medications reduce cerebral metabolic rate, all helping maintain normal ICP.
Question 2 of 5
The nurse on the brain injury unit observes a patient who displays inappropriate sexual behavior. What would be the best response by the nurse?
Correct Answer: C
Rationale: Pointing out unacceptable behavior sets clear boundaries and educates the patient on appropriate conduct.
Question 3 of 5
The nurse is reviewing discharge instructions for a patient with a spinal cord injury to T-10 going home with an indwelling urinary catheter. What would the nurse emphasize about catheter care?
Correct Answer: D,E
Rationale: Regular leg bag emptying prevents backflow and infection, and reporting foul-smelling, cloudy urine ensures early treatment of potential infections.
Question 4 of 5
A 21-year-old male was admitted to the emergency department following a high-speed motorcycle accident. He was reported to be unconscious at the scene, but upon arrival he was awake and oriented with a Glasgow Coma Scale (GCS) of 15. Suddenly, he becomes unconscious and mental status deteriorates to a GCS of 8. The nurse anticipates which of the following injuries?
Correct Answer: C
Rationale: Epidural hematoma presents with a lucid interval followed by sudden neurological decline due to rapid blood accumulation.
Question 5 of 5
A client has had a stapedectomy for otosclerosis 24 hours ago. What must the nurse teach the client about post-operative care?
Correct Answer: A
Rationale: Avoiding coughing or nose blowing prevents dislodging the stapes prosthesis, reducing complications.