ATI RN
ATI n300 Med Surg Exam Questions
Extract:
Question 1 of 5
The nurse is caring for a client in the burn unit with burns to the head, neck, chest back left arm and hand following an explosion in their garage. Upon admission, the nurse auscultates wheezes throughout all lung fields and applies oxygen via non-rebreather. One hour later, upon reassessment, the patient is visibly anxious and short of breath, wheezes cannot be heard, lung sounds are decreased, voice is hoarse, and the client is coughing up gray sputum. What is the most appropriate nursing action?
Correct Answer: A
Rationale: The absence of wheezes, decreased lung sounds, hoarseness, and gray sputum indicate progressive airway obstruction from inhalation injury, requiring immediate intubation.
Question 2 of 5
The nurse is viewing orders for a client with a suspected diagnosis of disseminated intravascular coagulation (DIC). The nurse recognizes that which laboratory test order set will most effectively guide the provider to a diagnosis of DIC?
Correct Answer: A
Rationale: D-dimer, fibrinogen, and fibrin degradation products reflect the clotting and fibrinolysis characteristic of DIC.
Question 3 of 5
The nurse is caring for a client who has completed a blood product transfusion for the treatment of thrombocytopenia. How would the nurse know that treatment has been successful?
Correct Answer: B
Rationale: The primary goal of platelet transfusion is to increase platelet count to reduce bleeding risk in thrombocytopenia.
Question 4 of 5
The nurse is caring for a client with SOB, wheezes, urticaria, itching and angioedema after receiving vancomycin IV. What is the priority nursing intervention after stopping the medication? Administer:
Correct Answer: C
Rationale: Epinephrine is the first-line treatment for anaphylaxis, reversing airway swelling, hypotension, and bronchoconstriction.
Question 5 of 5
What is included when the nurse performs the Glasgow Coma Score (GCS) on a client?
Correct Answer: B
Rationale: The GCS assesses eye opening, verbal response, and motor response to evaluate neurological status.