ATI RN
ATI Med Surg Nursing 300 Final Exam Questions
Extract:
Question 1 of 5
The nurse is caring for a patient in the Intensive Care Unit (ICU) with a ventriculostomy and intracranial pressure (ICP) reading of 30mmHg. The nurse notes a widened pulse pressure, irregular respirations. and bradycardia. The neurosurgeon instructs the nurse to drain cerebrospinal fluid. The nurse would also anticipate which medication administration order from the provider?
Correct Answer: A
Rationale: 3% Normal Saline reduces ICP by drawing fluid from brain tissue, addressing Cushing's triad (widened pulse pressure, irregular respirations, bradycardia). Nitroprusside and norepinephrine affect blood pressure, and furosemide is less effective for acute ICP.
Question 2 of 5
The client Is in the intensive care unit on a ventilator. Which intervention(s) should the nurse implement? (SELECT ALL THAT APPLY)
Correct Answer: A,B,E
Rationale: Hourly respiratory assessments detect changes early, a manual resuscitation bag is essential for emergencies, and collaboration with respiratory therapists ensures proper ventilator management. Pulse oximetry should be continuous, and nurses typically do not adjust ventilator settings.
Question 3 of 5
The neurologic assessment of a patient indicated impaired function of the glossopharyngeal nerve (CN 10) and the vagus nerve (C.N X). Based on these findings, the nurse plans to:
Correct Answer: B
Rationale: Impaired CN IX and X increase aspiration risk due to swallowing difficulties, so withholding oral intake is priority to prevent pneumonia.
Question 4 of 5
The nurse notices a yellow stain around fluid dripping from a patient's ear who sustained a traumatic brain injury. The nurse's priority intervention will be as follows:
Correct Answer: C
Rationale: Yellow-stained fluid suggests cerebrospinal fluid leak, a TBI complication. Allowing drainage prevents pressure buildup, and notifying the provider ensures further evaluation. Pressure dressings or antibiotics are premature, and IV fluids are unrelated.
Question 5 of 5
The nurse is teaching a client with type 2 diabetes mellitus about self-monitoring of blood glucose. Which statement by the client indicates understanding?
Correct Answer: B
Rationale: Using the sides of fingers for blood glucose sampling reduces pain and nerve damage, indicating correct technique.