ATI RN
ATI Med Surg Exam 3 Questions
Extract:
Question 1 of 5
What should the nurse do first when a client with a head injury begins to have clear drainage from the nose?
Correct Answer: D
Rationale: Collecting the drainage first helps identify if it is cerebrospinal fluid (CSF) or nasal secretions and monitors its characteristics. Compressing nares may increase intracranial pressure. Decongestants may mask CSF leakage. Tilting the head back may cause aspiration or infection.
Question 2 of 5
A client admitted to a medical-surgical unit for surgery has a history of Cushing's syndrome. Which physical assessment finding would the nurse expect to observe?
Correct Answer: A
Rationale: Buffalo hump and moon face are expected in Cushing's syndrome due to fat redistribution from excess cortisol. Dry skin suggests hypothyroidism. Dry mucous membranes suggest dehydration. Exophthalmos and tachycardia suggest hyperthyroidism.
Question 3 of 5
A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse notes there have not been any urinary output in the last hour. Which of the following actions should the nurse perform first?
Correct Answer: D
Rationale: Determining tubing patency first addresses potential obstructions. Antispasmodics, notifying the provider, or offering fluids do not resolve the immediate issue.
Question 4 of 5
A nurse is assisting with the care of a client who is 1 day postoperative following a thyroidectomy and reports severe muscle spasms of the lower extremities. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Determining calcium level addresses hypocalcemia, a thyroidectomy complication causing muscle spasms. Monitoring pulses, saline, or potassium do not address the issue.
Question 5 of 5
A client diagnosed with esophageal varices has a Sengstaken-Blakemore tube. What is the most important safety intervention for this client?
Correct Answer: A
Rationale: Keeping scissors at the bedside allows quick tube removal in case of airway obstruction or bleeding, prioritizing safety. Mouth care prevents infections but is less critical. Deflating the balloon may cause bleeding. Monitoring IV fluids prevents fluid overload but is not the most important.