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ATI Med Surg Custom N235 Final Summer 2023 Questions and Verified Answers with Rationales

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ATI Med Surg Custom N235 Final Summer 2023 Questions and Verified Answers with Rationales A nurse in an emergency department is preparing to care for a client who is beingbrought in with multiple system trauma following a motor vehicle crash. Which of thefollowing should the nurse identify as t...

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  • 27 de mayo de 2024
  • 27
  • 2023/2024
  • Examen
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  • ati med surg custom n235 final summer 2023 questio
  • a nurse in an emergency department is preparing to

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A nurse in an emergency department is preparing to care for a client who is being
brought in with multiple system trauma following a motor vehicle crash. Which of the
following should the nurse identify as the priority focus of care?
A. Preventing musculoskeletal disability 0% 
B. Airway protection 97% Most selected 
C. Stabilizing cardiac arrhythmias 2% 
D. Decreasing intracranial pressure 0% 
Answer and Explanation
Choice A:
Reason: Preventing musculoskeletal disability is important, but not the priority focus of
care. The nurse should first assess and manage the client's life-threatening injuries, such
as airway obstruction, bleeding, shock, or brain injury.
Choice B:
Reason: Airway protection is the priority focus of care for a client with multiple system
trauma. The nurse should ensure that the client has a patent airway and adequate
ventilation, as any compromise in these areas can quickly lead to hypoxia, respiratory
failure, and death.
Choice C:
Reason: Stabilizing cardiac arrhythmias is also important, but not the priority focus of
care. The nurse should monitor the client's cardiac rhythm and treat any arrhythmias
that may occur, but only after securing the airway and breathing.
Choice D:
Reason: Decreasing intracranial pressure is another important goal, but not the priority
focus of care. The nurse should assess the client's neurological status and intervene to
prevent or reduce increased intracranial pressure, such as elevating the head of the bed,
ATI Med Surg Custom N235 Final Summer 2023 maintaining normothermia, and administering osmotic diuretics. However, these
measures are secondary to ensuring adequate oxygenation and perfusion.
The nurse is caring for a postoperative client who has a chest tube connected to suction
and a water seal drainage system. Which of the following indicates to the nurse that the
chest tube is functioning properly?
A. Equal amount of fluid drainage in each collection chamber 6% 
B. Fluctuation of the fluid level within the water seal chamber 60% Most selected 
C. Continuous bubbling within the water seal chamber 30% 
D. Absence of fluid in the drainage tubing 3% 
Answer and Explanation
Choice A:
Reason: Equal amount of fluid drainage in each collection chamber is not a sign of
proper chest tube function. The amount of fluid drainage depends on the type and extent
of the client's injury or surgery, and may vary from one chamber to another.
Choice B:
Reason: Fluctuation of the fluid level within the water seal chamber is a sign of proper
chest tube function. It indicates that the chest tube is patent and that there is no air leak
in the system. The fluid level should rise and fall with the client's respiratory cycle.
Choice C:
Reason: Continuous bubbling within the water seal chamber is not a sign of proper chest
tube function. It indicates that there is an air leak in the system, either from the client's
pleural space or from a loose connection. The nurse should locate and correct the
source of the leak. Choice D:
Reason: Absence of fluid in the drainage tubing is not a sign of proper chest tube
function. It may indicate that the chest tube is obstructed, kinked, or clamped, or that the
suction is not working properly. The nurse should assess and troubleshoot the chest tube
system.
A nurse in the emergency department is caring for a client who has extensive partial and
full-thickness burns of the head, neck, and chest. While planning the client's care, the
nurse should identify which of the following risks as the priority for assessment and
intervention?
A. Infection 0% 
B. Airway obstruction 92% Most selected 
C. Paralytic ileus 0% 
D. Fluid imbalance 7% 
Answer and Explanation
Choice A:
Reason: Infection is a serious complication of burn injuries, but not the priority risk for
assessment and intervention. The nurse should monitor the client's wound healing,
temperature, white blood cell count, and signs of sepsis, and administer antibiotics as
prescribed. However, these measures are secondary to ensuring adequate oxygenation
and ventilation.
Choice B:
Reason: Airway obstruction is the priority risk for assessment and intervention for a client
who has burns of the head, neck, and chest. The nurse should assess the client's airway
patency, respiratory rate, oxygen saturation, breath sounds, and signs of respiratory
distress, such as stridor, wheezes, or cyanosis. The nurse should also provide humidified
oxygen, suction secretions, elevate the head of the bed, and prepare for endotracheal

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