ATI RN
ATI Advanced Med Surg Cohort 4 Exam Questions
Extract:
Question 1 of 5
The nurse in the emergency department is caring for a client who has fallen 20 feet from a roof. While performing the primary assessment, what is the most important nursing intervention?
Correct Answer: B
Rationale: Maintaining cervical spine precaution prevents further spinal cord injury in trauma patients until spinal injury is ruled out.
Question 2 of 5
A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?
Correct Answer: D
Rationale: A low GCS score indicates severe neurological impairment, suggesting the client is unconscious.
Extract:
Admission Assessment
Today:
0800:
The client states, "I got admitted because they said I have a really bad UTI."
The client reports dysuria for "about three days." The client developed fever this morning, so
they came to the emergency department to be evaluated. The client was found to have a urinary tract infection and was admitted for further care. They state they are still having bladder discomfort, but reports no other manifestations.
Medical history Hypertension, atrial fibrillation
Current Medications lisinopril 40mg PO daily, warfarin 2.5 mg PO daily
The client is in no acute distress. Oropharynx clear, mucous membranes moist, breath sounds clear bilaterally. Heart rate with regular rhythm and no murmur. CN II-XII intact, no weakness.
Nurses' Notes
Today:
0900:
The nurse is called to the client's room. The client reports headache with pain of 4 on a pain scale of 0 to 10 as throbbing. "I think my fever is better, but my head is killing me. Can I have something stronger for pain?"
0945:
The nurse is called again to the client's room. The client states, "You've got to help, something is wrong; this is the worst headache of my life." Client also reports ringing in the ears, photophobia, and left-sided weakness. They deny facial pain .
Client crying aphasia observed; oropharynx clear, mucous membranes moist, loss of peripheral vision. Breath sounds clear bilaterally; heart rate with regular rate, no murmur; negative Kernig and Brudzinski sign, left-sided upper and lower extremity weakness.
Provider Prescriptions
Today:
0800:
Acetaminophen 650mg PO every 8 hr PRN fever greater than 38˚C (100.4˚F) Hydrocodone/Ibuprofen 7.5/200 mg PO every 8 hr PRN pain
Lisinopril 40mg PO daily Warfarin 2.5 mg PO daily
Ciprofloxacin 500 mg PO BID x 7 days
Laboratory Results
Today:
0800:
WBC 11,000 mm3 (5,000 to 10,00mm3)
Urinalysis
Appearance clear
Color dark amber
pH 6 (4.6 to 8)
Protein 2 mg/dL (0 to 8 mg/dL)
Leukocyte esterase positive
Nitrites positive
Ketones none
Bilirubin none
Blood positive
INR: 4.9 (0.8 to 1.1)
Vital Sign
Today:
0800:
Temperature 38.1˚C (100.5˚F)
Heart Rate 89/min
Respiratory Rate 19/min
Blood Pressure 119/85 mmHg
SaO2 98% on room air
0930:
Temperature 37.2˚C (98.9˚F)
Heart Rate 62/min
Respiratory Rate 19/min
Blood Pressure 159/83 mmHg
SaO2 93% on room air
Medication Administration Record
0800:
Acetaminophen 650 mg PO 0900:
Hydrocodone/Ibuprofen 7.5/200 mg PO
Question 3 of 5
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Correct Answer: B (Hemorrhagic Stroke), A (Prepare for STAT CT, Seizure precautions), C (Temperature, PT/INR)
Rationale: Sudden severe headache, neurological symptoms, and elevated INR suggest hemorrhagic stroke, requiring urgent CT and seizure precautions, with monitoring of temperature and PT/INR.
Extract:
Question 4 of 5
A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following medication would the nurse anticipate to administer?
Correct Answer: B
Rationale: IV lorazepam is the first-line treatment for acute seizure termination, acting quickly to suppress seizure activity.
Question 5 of 5
Which information about the patient who had a subarachnoid hemorrhage is most important to communicate to the health care provider?
Correct Answer: D
Rationale: Hypotension indicates potential hemodynamic instability, requiring urgent intervention to ensure cerebral perfusion in subarachnoid hemorrhage.