ATI RN
ATI Nurs285 Med Surg Exam Questions
Extract:
Question 1 of 5
Which assessment data would warrant immediate intervention by the nurse?
Correct Answer: C
Rationale: Pain on inspiration in a client with deep vein thrombosis may indicate a pulmonary embolism, a life-threatening condition requiring immediate assessment and intervention.
Question 2 of 5
A nurse is assessing the respiratory status of a client who has suffered a fractured rib. Which observation, if made by the nurse, would not be directly related to the fractured rib?
Correct Answer: A
Rationale: Pleural effusion on the unaffected side is not directly related to a fractured rib and is likely caused by another condition, such as infection or malignancy. Shallow breathing, guarding, and localized pain are expected with rib fractures.
Question 3 of 5
A nurse is caring for a client who is receiving heparin 3,800 units subcutaneous daily. Available is heparin 5,000 units/mL. How many mL should the nurse administer?
Correct Answer: B
Rationale: Using the proportion: 3,800 units / 5,000 units/mL = 0.76 mL, rounded to 0.8 mL to the nearest tenth.
Question 4 of 5
A patient is admitted to the respiratory unit with flail chest. The nurse understands that a flail chest is:
Correct Answer: A
Rationale: Flail chest is characterized by multiple rib fractures creating a free-floating chest wall segment that moves paradoxically, impairing ventilation. Other options describe different conditions.
Question 5 of 5
A client receiving low molecular weight heparin subcutaneously to prevent DVT following hip replacement surgery reports to the nurse that she observed small purple hemorrhagic areas on the right and left sides of the abdomen. Which action should the nurse implement?
Correct Answer: B
Rationale: Small hemorrhagic areas (ecchymosis) at injection sites are a common side effect of low molecular weight heparin and do not require immediate escalation.