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 nurse enters the room of a client with type 1 diabetes mellitus and finds the client difficult to arouse. The client's skin is warm and flushed and the pulse and respiratory rate are increased from the client's baseline. The nurse would first take which action?
Correct Answer: C
Rationale: Checking blood glucose first determines if the client has hyperglycemia or hypoglycemia, guiding treatment. Insulin, orange juice, or dextrose may be inappropriate without this information.
Question 3 of 5
A nurse is reviewing data for a client who has a head injury. Which of the following findings should indicate to the nurse that the client might have diabetes insipidus?
Correct Answer: A
Rationale: Urine output of 800 mL/hr indicates diabetes insipidus due to large amounts of diluted urine from ADH deficiency. Blood glucose of 198 mg/dL suggests diabetes mellitus. Serum sodium of 145 mEq/L is normal. Urine specific gravity of 1.028 indicates concentrated urine.
Question 4 of 5
The nurse is participating in a care planning conference for a patient with acquired immunodeficiency syndrome (AIDS). What is the nurse's highest priority in providing care to this client?
Correct Answer: A
Rationale: Preventing infection is the highest priority for AIDS patients due to immune system impairment and risk of opportunistic infections. Emotional support, identifying risk factors, and discussing causes are less urgent.
Question 5 of 5
A client is transported to the recovery area of the ambulatory care unit after cataract surgery. In which position does the nurse place the client?
Correct Answer: D
Rationale: Semi Fowler's position reduces intraocular pressure and promotes healing post-cataract surgery. Side lying, supine, or prone positions may increase pressure or swelling.