ATI RN
ATI Med Surg Nursing 300 Final Exam Questions
Extract:
Question 1 of 5
The nurse is caring for a patient with an acute head injury. Which assessment finding would first alert the nurse that the patient is developing an increase in intracranial pressure (ICP)?
Correct Answer: C
Rationale: Altered level of consciousness is the earliest sign of increased ICP, reflecting brain compression. Sluggish pupils and widening pulse pressure are later signs, and tachycardia with hypotension is not typical.
Question 2 of 5
The nurse is evaluating the outcomes for a client diagnosed with disseminated intravascular coagulation (DIC). Which laboratory value reflects a positive outcome?
Correct Answer: D
Rationale: A decreased D-dimer level indicates reduced fibrinolysis and resolution of DIC, a positive outcome. Prolonged PT and decreased platelets are signs of ongoing DIC, and fibrinogen is typically low, not elevated.
Question 3 of 5
The nurse is caring for a client who has a biventricular pacemaker. Which instruction should the nurse include in the discharge teaching?
Correct Answer: C
Rationale: No heavy lifting for 6-8 weeks prevents pacemaker lead dislodgement, a critical instruction for recovery.
Question 4 of 5
The nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which assessment finding indicates a complication of TPN therapy?
Correct Answer: A
Rationale: Blood glucose of 180 mg/dL indicates hyperglycemia, a common TPN complication due to high dextrose content, requiring insulin or rate adjustment.
Question 5 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.