ATI RN
ATI n300 Med Surg Exam Questions
Extract:
Question 1 of 5
The nurse is caring for an elderly client with type II diabetes who has had nausea, vomiting and diarrhea for several days and who now is disoriented and listless. Initial vital signs: B/P 72/62, pulse 146 irregular and thready, respirations 38 breaths per minute and shallow, and temperature of 97.0 F rectally. The skin is cool and clammy. The nurse recognizes that this client's symptoms are most indicative of which stage and type of shock? The:
Correct Answer: C
Rationale: The client shows signs of hypovolemic shock from fluid loss, with progressive stage indicated by hypotension, tachycardia, and altered mental status.
Question 2 of 5
The nurse is caring for a patient with major burns Total Body Surface Area (TBSA) of 63%. The nurse understands that this patient is at the highest risk for the combination of which types of shock? (Select All that Apply.)
Correct Answer: A,D
Rationale: Severe burns cause hypovolemic shock from fluid loss and distributive shock from systemic inflammatory response syndrome (SIRS).
Question 3 of 5
The nurse is caring for a client who received a blunt force injury to zone II of the neck. Which assessment finding should the nurse report to the physician IMMEDIATELY?
Correct Answer: C
Rationale: Dysphonia or dysphagia indicate airway compromise, requiring immediate attention.
Question 4 of 5
The nurse is caring for a client in the burn unit with burns to the head, neck, chest back left arm and hand following an explosion in their garage. Upon admission, the nurse auscultates wheezes throughout all lung fields and applies oxygen via non-rebreather. One hour later, upon reassessment, the patient is visibly anxious and short of breath, wheezes cannot be heard, lung sounds are decreased, voice is hoarse, and the client is coughing up gray sputum. What is the most appropriate nursing action?
Correct Answer: A
Rationale: The absence of wheezes, decreased lung sounds, hoarseness, and gray sputum indicate progressive airway obstruction from inhalation injury, requiring immediate intubation.
Question 5 of 5
The nurse is caring for a client with a spinal cord injury at C3. The nurse notices on the cardiac monitor a heart rate of 30 beats per minute & upon assessment of the patient, a change in mental status. What medication does the nurse anticipate will be ordered by the physician STAT?
Correct Answer: A
Rationale: Atropine is the first-line treatment for symptomatic bradycardia caused by disrupted sympathetic control in a C3 spinal cord injury.