ATI ADVANCED MED SURG PROCTORED 2024 WITH GLASGOW COMA 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’s spouse 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?xtrose in water
• 5?xtrose 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 if the client has acute pancreatitis?

• Decreased WBC