ATI RN
ATI Med Surg Exam N300 Exam Day Questions
Extract:
Question 1 of 5
The nurse is caring for a patient with an acute brain injury. Which of the following sets of vital signs would concern the nurse about increasing intracranial pressure (ICP)?
Correct Answer: B
Rationale: This set of vital signs is concerning due to the extremely high blood pressure (220/46) combined with a very low heart rate (30) and low respiratory rate (6), which can indicate an autonomic response to increased ICP, potentially leading to Cushing's triad.
Question 2 of 5
The healthcare provider has prescribed intravenous (IV) lorazepam for the patient in status epilepticus. During administration, which is the priority assessment by the nurse?
Correct Answer: C
Rationale: Pulse oximetry is the priority assessment as IV lorazepam can depress the respiratory system, leading to hypoxia. Monitoring oxygen saturation helps ensure the patient maintains adequate respiratory function during administration.
Question 3 of 5
When considering the pharmacologic management of a patient who has sustained a traumatic head injury, the nurse can anticipate a prescription for which of the following medications to manage increases in intracranial pressure (ICP)?
Correct Answer: C
Rationale: Hypertonic saline (3% Normal Saline) is used to reduce intracranial pressure by drawing fluid out of the brain tissue and into the bloodstream, which can help prevent cerebral edema.
Question 4 of 5
The provider has prescribed timolol ophthalmic drops for the patient diagnosed with glaucoma. The nurse should assess the patient for which of the following side effects?
Correct Answer: A
Rationale: Timolol is a beta-blocker that can be absorbed systemically, leading to side effects such as bradycardia and hypotension, which require monitoring.
Question 5 of 5
The nurse on the brain injury unit observes a patient who displays inappropriate sexual behavior. What would be the best response by the nurse?
Correct Answer: B
Rationale: Pointing out the behavior as unacceptable provides immediate feedback and helps the patient understand social boundaries, which can be challenging post-brain injury. This approach is direct and respectful, focusing on redirection rather than punishment.