ATI RN
ATI EW N300 Med Surg Exam Questions
Extract:
Question 1 of 5
The nurse is caring for a patient with a spinal cord injury at the level of C-7. The patient is having a severe headache, hypertension, bradycardia, diaphoresis, and flushing of the face with pale, cold skin below the level of the injury. What are the priority nursing interventions?
Correct Answer: A
Rationale: These interventions address autonomic dysreflexia by reducing blood pressure and removing triggers like catheter obstruction.
Question 2 of 5
A nurse is caring for a client who has had repeated instances of cystitis. When considering possible ascending progression of the infection, the client should be taught to monitor for:
Correct Answer: C
Rationale: Flank pain and fever indicate pyelonephritis, signaling ascending infection from the bladder to the kidneys, requiring immediate attention.
Question 3 of 5
A nurse is the first person on the scene of a motor vehicle accident. The victim was the driver and is in the driver's seat unconscious. The driver is breathing, has a pulse, and has minor lacerations on the head and face. What action should the nurse implement first?
Correct Answer: A
Rationale: Stabilizing the cervical spine prevents further spinal injury in trauma patients.
Question 4 of 5
The nurse is caring for a patient diagnosed with a traumatic head injury secondary to a work accident. In the morning assessment, the patient opened his eyes in response to noxious stimuli. Two hours later, what assessment finding would warrant immediate action by the nurse? The patient:
Correct Answer: D
Rationale: Extending extremities in response to painful stimuli, known as decerebrate posturing, is a severe neurologic deficit indicating brainstem dysfunction and requires immediate nursing intervention.
Question 5 of 5
The client is being discharged from the ambulatory care unit following cataract removal. The nurse provides instructions regarding home care. Which of the following, if stated by the client, indicates an understanding of the instructions?
Correct Answer: C
Rationale: Eye shields at night and glasses during the day protect the operative site, supporting proper healing post-cataract surgery.