ATI ADVANCED MED SURG PROCTORED 2023 WITH
GLASGOWCOMA SCALE REAL EXAM
• 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’sspouse asks
the nurse what the procedure entails. Which of the following
nursing statements is appropriate?
• “large incisions will be made in the eschar to improve circulation”
• “ I can call the doctor back here if you want me to”
• “a piece of skin will be removed and grafted over the burned area”
• “dead tissue will be surgically removed”
• 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?
• 5% dextrose in water
• 5% dextrose in normal saline
• normal saline
• 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?
• auscultate cuff blood pressure
• palpate pulse pressure
• obtain a central venous pressure
• monitor the pulmonary artery pressure
• A nurse is assessing the depth and extent of a client who has severe burns to the face,
neck, and upper extremities. Which of the following factors is the first priority when
assessing the severity of the burn?
• Age of the client
• Associated medical history
• Location of the burn
• Cause of the burn
• A client arrives at the emergency dept following an explosion at the chemical plant.
He has deep partial and full-thickness chemical burns over more than 25 %of his body
surface area. What is the nurse’s priority intervention?
• Initiate fluid resuscitation
• Medication for pain
,• Administer antibiotics
• Maintain a patent airway
• A nurse is caring for a client who came the emergency dept reporting chest pain. The
provider suspects a myocardial infarction. While waiting for the laboratory to report the
client’s troponin levels, the client asks what this blood test will show.
The nurse should explain that troponin is
• An enzyme that indicates damage to brain, heart, and skeletal muscle
tissues
• A protein whose levels reflect the risk for coronary artery disease
• A heart muscle protein that appears in the bloodstream when there is
damage to the heart
• A protein that helps transport oxygen throughout the body
• A nurse is assessing a client who has disseminated intravascular coagulation
(DIC). Which of the following should the nurse expect in the findings?
• Excessive thrombosis and bleeding
• Progressive increase in platelet production
• Immediate sodium and fluid retention
• Increased clotting factors
• A nurse is about to administer warfarin (Coumadin) to a client who has atrial
fibrillation. When the client asks what his medication will do, which of the following
is an appropriate nursing response?
• It helps convert atrial fibrillation to sinus rhythm
• Is dissolves clots in the bloodstream
• It slows the response of the ventricles to the fast atrial impulses
• It prevents strokes in clients who have atrial fibrillation
• A nurse in a cardiac care unit is caring for a client with acute heart failure. Which of the
following findings should the nurse expect?
• Decreased brain natriuretic peptide (BNP)
• Elevated central venous pressure (CVP)
• Decreased pulmonary pressure
• Increases urinary output
• A client comes into the ED reporting nausea and vomiting that worsens when lying
down and without relief from antacids. The provider suspects acute pancreatitis. Which
, of the following lab test results should the nurse expect to see ifthe client has acute
pancreatitis?
• Decreased WBC
• Increased serum amylase
• Decreased serum lipase
• Increased serum calcium
• A nurse in the ICU is caring for a client who has acute respiratory distress
syndrome (ARDS) and is receiving mechanical via an endotracheal tube. The
provider plans to extubate her within the next 24 hour. Which of the following isan
important criterion for extubating the client?
• Ability to cough effectively
• Adequate tidal volume without manually assisted breaths
• No indication of infection
• No need for supplemental oxygen
• A nurse is caring for a client following a CT scan with dye who suffered from an
anaphylactic reaction. Which of the following conditions requires a priority nursing
response?
• urticaria
• stridor
• tachypnea
• angioedema
• A nurse is caring for a female client who came in to the ED reporting SOB and pain
in the lung area. Her heart rate is 110/min, resp. rate 40/min, and blood pressure
140/80 m8juiimHg. Her arterial blood gases are: pH 7.5, PaCO2 29 mmHg,PaO2 60 mm
Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority intervention?
• Prepare for mechanical ventilation
• Administer oxygen via face mask
• Prepare to administer a sedative
• Monitor for pulmonary embolism
• A nurse is monitoring a client who has just had a thoracentesis to remove pleuralfluid.
Which of the following clinical manifestations indicate a complication that requires
notifying the provider immediately?
• Serosanguineous drainage from the puncture site
• Discomfort at the puncture site
• Increased heart rate
GLASGOWCOMA SCALE REAL EXAM
• 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’sspouse asks
the nurse what the procedure entails. Which of the following
nursing statements is appropriate?
• “large incisions will be made in the eschar to improve circulation”
• “ I can call the doctor back here if you want me to”
• “a piece of skin will be removed and grafted over the burned area”
• “dead tissue will be surgically removed”
• 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?
• 5% dextrose in water
• 5% dextrose in normal saline
• normal saline
• 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?
• auscultate cuff blood pressure
• palpate pulse pressure
• obtain a central venous pressure
• monitor the pulmonary artery pressure
• A nurse is assessing the depth and extent of a client who has severe burns to the face,
neck, and upper extremities. Which of the following factors is the first priority when
assessing the severity of the burn?
• Age of the client
• Associated medical history
• Location of the burn
• Cause of the burn
• A client arrives at the emergency dept following an explosion at the chemical plant.
He has deep partial and full-thickness chemical burns over more than 25 %of his body
surface area. What is the nurse’s priority intervention?
• Initiate fluid resuscitation
• Medication for pain
,• Administer antibiotics
• Maintain a patent airway
• A nurse is caring for a client who came the emergency dept reporting chest pain. The
provider suspects a myocardial infarction. While waiting for the laboratory to report the
client’s troponin levels, the client asks what this blood test will show.
The nurse should explain that troponin is
• An enzyme that indicates damage to brain, heart, and skeletal muscle
tissues
• A protein whose levels reflect the risk for coronary artery disease
• A heart muscle protein that appears in the bloodstream when there is
damage to the heart
• A protein that helps transport oxygen throughout the body
• A nurse is assessing a client who has disseminated intravascular coagulation
(DIC). Which of the following should the nurse expect in the findings?
• Excessive thrombosis and bleeding
• Progressive increase in platelet production
• Immediate sodium and fluid retention
• Increased clotting factors
• A nurse is about to administer warfarin (Coumadin) to a client who has atrial
fibrillation. When the client asks what his medication will do, which of the following
is an appropriate nursing response?
• It helps convert atrial fibrillation to sinus rhythm
• Is dissolves clots in the bloodstream
• It slows the response of the ventricles to the fast atrial impulses
• It prevents strokes in clients who have atrial fibrillation
• A nurse in a cardiac care unit is caring for a client with acute heart failure. Which of the
following findings should the nurse expect?
• Decreased brain natriuretic peptide (BNP)
• Elevated central venous pressure (CVP)
• Decreased pulmonary pressure
• Increases urinary output
• A client comes into the ED reporting nausea and vomiting that worsens when lying
down and without relief from antacids. The provider suspects acute pancreatitis. Which
, of the following lab test results should the nurse expect to see ifthe client has acute
pancreatitis?
• Decreased WBC
• Increased serum amylase
• Decreased serum lipase
• Increased serum calcium
• A nurse in the ICU is caring for a client who has acute respiratory distress
syndrome (ARDS) and is receiving mechanical via an endotracheal tube. The
provider plans to extubate her within the next 24 hour. Which of the following isan
important criterion for extubating the client?
• Ability to cough effectively
• Adequate tidal volume without manually assisted breaths
• No indication of infection
• No need for supplemental oxygen
• A nurse is caring for a client following a CT scan with dye who suffered from an
anaphylactic reaction. Which of the following conditions requires a priority nursing
response?
• urticaria
• stridor
• tachypnea
• angioedema
• A nurse is caring for a female client who came in to the ED reporting SOB and pain
in the lung area. Her heart rate is 110/min, resp. rate 40/min, and blood pressure
140/80 m8juiimHg. Her arterial blood gases are: pH 7.5, PaCO2 29 mmHg,PaO2 60 mm
Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority intervention?
• Prepare for mechanical ventilation
• Administer oxygen via face mask
• Prepare to administer a sedative
• Monitor for pulmonary embolism
• A nurse is monitoring a client who has just had a thoracentesis to remove pleuralfluid.
Which of the following clinical manifestations indicate a complication that requires
notifying the provider immediately?
• Serosanguineous drainage from the puncture site
• Discomfort at the puncture site
• Increased heart rate
