Exam 5 ATI questions
a nurse is caring for a client with an abdominal aortic aneurysm and is scheduled for surgery. the clients vitals are blood pressure 160/98, heart rate 102, respirations 22, and oxygen saturation 95%. what action should the nurse take?
administer an antihypertensive medication for blood pressure
a nurse in the ED is assessing a client who sustained a fall off a roof. what finding would indicate that the client has a basilar skull fracture?
clear fluid coming from the nares
a nurse is caring for a client who experienced a traumatic brain injury. which of the following findings indicates the client has increased intracranial pressure?
dilated pupils
a nurse in the ED is caring for a toddler who is in acute respiratory distress. what finding should alert the nurse to the possibility of epiglottitis?
drooling
a nurse is performing a pre-op assessment on a client that is about to undergo an aneurysm clipping. the nurse should identify a risk for increased bleeding when the client reports taking what dietary supplement?
garlic
a nurse is teaching a client who has a spinal cord injury to perform intermittent urinary self-catheterization at home after discharge. what statement indicates that the client understands the procedure?
i will perform intermittent urinary self-catheterization every 2-3 hours
a nurse in the ED has assessed a client's ABC's following a head injury from a fall at work. what action is a priority for the nurse to perform next?
immobilize the client's cervical spine
a nurse is assessing a client with an abdominal aortic aneurysm. which manifestation should the nurse expect?
lower back discomfort
a nurse is caring for a client who is experiencing autonomic dysreflexia due to a C5 spinal cord injury. after checking the client's vital signs, what action should the nurse perform next?
place the client in high fowlers position
a nurse in the ED is assessing a client with a new traumatic brain injury and observes extension of the client's arms and legs, pronation of the arms, and plantar flexion of the feet. Which of the following is the nurse's priority?
provide supplemental oxygen
a nurse is assessing a client who has a high thoracic spinal cord injury. the nurse should identify what finding as a manifestation of autonomic dysreflexia?
report of a headache
a nurse is assessing a client with an abdominal aortic aneurysm (AAA). what finding indicates the aneurysm is expanding?
report of sudden, severe back pain
a nurse is caring for a client with a closed traumatic brain injury and is experiencing increased ICP. the increased ICP is due to what?
rigid skull containing cranial contents
a nurse is assessing a preschooler who has influenzae and reports new onset of a sore throat and difficulty swallowing. what finding is a priority is report to the provider?
the child is drooling
a nurse is caring for a client who has a TBI and assumes a decerebrate posture in response to noxious stimuli. what reaction should the nurse anticipate when drawing a blood sample?
the client rigidly extends his arms
a nurse in the ED is caring for a group of clients who all have alcohol odor on their breath and multiple injuries to the head and extremities. Who should the nurse see first?
the client that is difficult to arouse and is unable to respond to questions
