ATI RN
ATI Med Surg Nursing 300 Final Exam Questions
Extract:
Question 1 of 5
The nurse is caring for patient with severe, major burns who is receiving fluid resuscitation per protocol. Which of the following assessments indicate positive outcome?
Correct Answer: A
Rationale: Urine output of 0.5-1 mL/kg/hr indicates adequate renal perfusion, a positive outcome in burn fluid resuscitation.
Question 2 of 5
The nurse is caring for a client who is receiving mechanical ventilation. Which action should the nurse take to prevent ventilator-associated pneumonia?
Correct Answer: B
Rationale: Regular oral care reduces oral bacteria, decreasing the risk of ventilator-associated pneumonia.
Question 3 of 5
The neurologic assessment of a patient indicated impaired function of the glossopharyngeal nerve (CN 10) and the vagus nerve (C.N X). Based on these findings, the nurse plans to:
Correct Answer: B
Rationale: Impaired CN IX and X increase aspiration risk due to swallowing difficulties, so withholding oral intake is priority to prevent pneumonia.
Question 4 of 5
A 45-year-old patient presents to the trauma unit after a gunshot wound (GSW) to the abdomen. The patient has a temperature of 92 degrees Fahrenheit, is restless and confused, and has large amount of blood noted from the nasogastric (NG) tube as well as from the indwelling urinary catheter. Which additional assessment finding likely causes death within the first 24 hours following this injury?
Correct Answer: B
Rationale: A pH of 7.21 indicates severe acidosis, likely from hypoperfusion and shock due to massive blood loss, a leading cause of death in abdominal trauma. Tachycardia is compensatory, hyperkalemia is concerning but less immediate, and platelets are normal.
Question 5 of 5
A nurse is caring for a client who has suspected hemorrhagic stroke from a ruptured cerebral aneurysm. Which of the following manifestations would the nurse expect?
Correct Answer: D
Rationale: A sudden, severe headache ('worst headache of my life') is classic for a ruptured cerebral aneurysm, causing hemorrhagic stroke.