ATI RN
ATI Medsurg Exam 5 Questions
Extract:
Question 1 of 5
The nurse is assessing for Jaundice on a client diagnosed with liver disease. Which of the following should the nurse document as an assessment finding for jaundice?
Correct Answer: A
Rationale: Jaundice causes yellowing of the sclera due to bilirubin buildup, visible in normal light, unlike nail deposits or iris involvement.
Question 2 of 5
The nurse documents the blood pressure on a client to be 158/94 mm Hg when lying in bed, 13 mm Hg when sitting in a chair, and 98/60 mm Hg when standing. The nurse should recognize which of the following as the evaluation of this?
Correct Answer: A
Rationale: The significant drop in blood pressure upon standing indicates orthostatic hypotension, not hypertension or normal variation.
Question 3 of 5
The nurse is caring for a client with stage 2 pressure ulcer. The nurse should document which of the following as characteristic of a stage II pressure ulcer?
Correct Answer: D
Rationale: Stage II pressure ulcers involve partial-thickness loss with open blisters and a red-pink wound bed, not eschar or subcutaneous involvement.
Question 4 of 5
A client tells the nurse that he is allergic to penicillin. Which of the following is the best response by the nurse?
Correct Answer: D
Rationale: Asking the client to describe their reaction clarifies the allergy's nature and severity, guiding safe care planning.
Question 5 of 5
A client at the clinic for an annual wellness physical denies experiencing any acute health problems. The nurse should utilize which open-ended general lead to begin the interview?
Correct Answer: C
Rationale: An open-ended question like 'How has your health been since your last visit?' encourages the client to share relevant health information without assumptions, unlike the other options.