ATI ADVANCED MED-SURG PROCTORED 2023 WITH GLASGOW COMA EXAM QUESTIONS AND ANSWERS
ALREADY GRADED A+
1. 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 - answer-"large incisions will be made
in the eschar to improve circulation"
2. 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? - answer-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? - answer-obtain a central venous 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? - answer-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? - answer-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 - answer-A heart muscle protein that appears in the
bloodstream when there is damage to the heart
A nurse is assessing a client who has disseminated intravascular coagulation
(DIC). Which of the following should the nurse expect in the findings? - answer-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? - answer-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? - answer-Elevated central venous pressure (CVP)
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 if
the client has acute pancreatitis? - answer-Increased serum amylase
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 is
an important criterion for extubating the client? - answer-Adequate tidal volume without manually
assisted breaths
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? - answer-stridor
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? - answer-Administer oxygen via face mask
, A nurse is monitoring a client who has just had a thoracentesis to remove pleural
fluid. Which of the following clinical manifestations indicate a complication that
requires notifying the provider immediately? - answer-Increased heart rate
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? - answer-inspect mouth for signs of inhalation
A triage nurse in an emergency dept is caring for a client who has 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? - answer-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? - answer-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 mL/hr. The client begins to
complain of low back pain and headache and is increasingly restless. What is the
first nursing action? - answer-Stop the transfusion, disconnect the blood tubing, and begin a
primary infusion of normal saline solution
A client with a diagnosis of disseminated intravascular coagulation (DIC) has the
ALREADY GRADED A+
1. 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 - answer-"large incisions will be made
in the eschar to improve circulation"
2. 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? - answer-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? - answer-obtain a central venous 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? - answer-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? - answer-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 - answer-A heart muscle protein that appears in the
bloodstream when there is damage to the heart
A nurse is assessing a client who has disseminated intravascular coagulation
(DIC). Which of the following should the nurse expect in the findings? - answer-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? - answer-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? - answer-Elevated central venous pressure (CVP)
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 if
the client has acute pancreatitis? - answer-Increased serum amylase
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 is
an important criterion for extubating the client? - answer-Adequate tidal volume without manually
assisted breaths
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? - answer-stridor
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? - answer-Administer oxygen via face mask
, A nurse is monitoring a client who has just had a thoracentesis to remove pleural
fluid. Which of the following clinical manifestations indicate a complication that
requires notifying the provider immediately? - answer-Increased heart rate
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? - answer-inspect mouth for signs of inhalation
A triage nurse in an emergency dept is caring for a client who has 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? - answer-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? - answer-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 mL/hr. The client begins to
complain of low back pain and headache and is increasingly restless. What is the
first nursing action? - answer-Stop the transfusion, disconnect the blood tubing, and begin a
primary infusion of normal saline solution
A client with a diagnosis of disseminated intravascular coagulation (DIC) has the
