ATI RN
ATI Med Surg Custom N235 Final Summer 2023 Questions
Extract:
Question 1 of 5
The nurse is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly?
Correct Answer: B
Rationale: Fluctuation in the water seal chamber indicates the chest tube is patent and functioning, reflecting normal respiratory pressure changes.
Question 2 of 5
A nurse is caring for a client who has a traumatic brain injury. The nurse notes that the client has a widening pulse pressure. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Widening pulse pressure suggests increased ICP; elevating the head to 30° reduces it.
Question 3 of 5
A nurse is preparing to administer medications to four clients. The nurse should administer medications to which of the following clients first?
Correct Answer: C
Rationale: Hyperkalemia (5.8 mEq/L) is life-threatening and requires immediate intervention with sodium polystyrene sulfonate.
Question 4 of 5
A nurse is preparing to administer blood to a client. The unit of blood on hand is type B, and the client has type AB blood. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Type AB clients can safely receive type B blood because AB has no antibodies against B antigens, making administration appropriate.
Question 5 of 5
A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2°C (100.8°F). Which of the following neurologic disorders should the nurse suspect?
Correct Answer: D
Rationale: Sudden headache, seizure, and hypertension suggest a hemorrhagic stroke, likely from a ruptured vessel.