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• A nurse in a burn treatment center is caring for a client who is
admitted with severe burns to both lower extremities and is pending
an escharotomy. The client’s spouse asks the nurse what the procedure
entails. Which of the following nursing statements is appropriate?
a. “large incisions will be made in the eschar to improve circulation”
b. “ I can call the doctor back here if you want me to”
c. “a piece of skin will be removed and grafted over the burned area”
d. “dead tissue will be surgically removed”
• A group of college students was attending a weekend football rally
when one of the students stumbled and fell into the bonfire. Although
several friends quickly intervened, the client sustained partial-
thickness burns to both lower legs, chest, and both forearms. Which of
the following is priority nursing action when the client is brought to
the ED?
a. cover the burned area with sterile gauze
b. inspect mouth for signs of inhalation
c. administer intravenous pain medication
d. draw blood for a CBC
• A triage nurse in an emergency dept is caring for a client who has
MED SURG 3480 ATI Advanced FINAL EXAM
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,MED SURG 3480 ATI Advanced FINAL EXAM
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gunshot wound to the right side of chest. The nurse notices thick
dressing on the chest and sucking noise coming from the wound. The
client has a blood pressure of 100/60 mm Hg, a weak pulse rate of
118/min, and a respiratory rate of 40/min. Which of the following
actions should the nurse take initially?
a. Raise the foot of the bed to a 90 degree angle
b. Remove the dressing to inspect the wound
c. Prepare to insert a central line
d. Administer oxygen via nasal cannula
• A nurse is suctioning the endotracheal tube of a client who is on a
ventilator. The client’s heart rate increases from 86/min to 110/min
and becomes irregular. The nurse should know that the client requires
which of the following?
a. A cardiology consult
b. Less frequent suctioning
c. An antidysrhythmic medication
d. Pre-oxygenation prior to suctioning
• The nurse is caring for a client who is receiving a blood
transfusion. The transfusion started 30 minutes ago at a rate of 100
MED SURG 3480 ATI Advanced FINAL EXAM
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,MED SURG 3480 ATI Advanced FINAL EXAM
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mL/hr. The client begins to complain of low back pain and headache
and is increasingly restless. What is the first nursing action?
a. Stop the transfusion, disconnect the blood tubing,
and begin a primary infusion of normal saline solution
b. Slow the infusion and evaluate the vital signs and the client’s
history of tranfusion reactions
c. Slow the infusion of blood and begin infusion of normal
saline solution from the Y connector.
d. Recheck the unit of blood for correct identification
numbers and crossmatch information
• A client with a diagnosis of disseminated intravascular coagulation
(DIC) has the following assessment findings: blood pressure of 76/56,
temperature 102.6 degrees, resp. 24 breath/min., with complaints of
severe neck and back pain.
Which nursing action should the nurse implement first?
a. Administer acetaminophen (Tylenol) PO.
MED SURG 3480 ATI Advanced FINAL EXAM
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b. Administer ibuprofen (Motrin) PO.
c. Draw coagulation study blood work in the AM
d. Give morphine sulfate IV
• A nurse is monitoring the fluid replacement of a client who has
sustained burns. Which of the following fluids is used in the first 24
hours following a burn injury?
a. 5% dextrose in water
b. 5% dextrose in normal saline
c. normal saline
d.lactated ringers
• A nurse is caring for a client who has full-thickness burns all over
75% of his body. Which of the following methods is appropriate to
accurately monitor the cardiovascular system?
a. auscultate cuff blood pressure
b. palpate pulse pressure
c. obtain a central venous pressure
d. monitor the pulmonary artery pressure
MED SURG 3480 ATI Advanced FINAL EXAM
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