ATI RN 231 Quiz 4 Assessment 1 –
Verified Questions and Rationales
(2024/2025 Edition)
1. Multiple-Choice
Question: A nurse is caring for a client admitted to the emergency department with
extensive partial and full-thickness burns to the head, neck, and chest. What is the
priority nursing action?
A) Administer IV fluids
B) Assess airway patency
C) Apply topical antibiotics
D) Insert a urinary catheter
Answer: B) Assess airway patency
Rationale: Burns to the head, neck, and chest can compromise the airway due to swelling
or inhalation injury. Airway assessment is the priority to ensure breathing. Fluid
resuscitation follows after airway and breathing are secured.
2. Multiple-Response
Question: A nurse is planning care for a client with a 30% total body surface area
(TBSA) burn. Which interventions should be included? (Select all that apply.)
A) Monitor for hypothermia
B) Administer tetanus prophylaxis
C) Provide high-protein, high-calorie diet
D) Restrict fluids to prevent edema
Answers: A, B, C
Rationale: Burns increase hypothermia risk due to skin loss, require tetanus prophylaxis
for wound infection prevention, and necessitate a high-protein, high-calorie diet for
healing. Fluid restriction is inappropriate as burns require aggressive fluid resuscitation.
3. Fill-in-the-Blank
Question: A client with a 40% TBSA burn requires fluid resuscitation using the Parkland
formula. The client weighs 70 kg. The nurse should administer __________ mL of
lactated Ringer’s in the first 8 hours.
Answer: 5,600
Rationale: The Parkland formula is 4 mL × TBSA (%) × weight (kg). For 40% TBSA
and 70 kg: 4 × 40 × 70 = 11,200 mL total, with half (5,600 mL) given in the first 8 hours.
4. Drag-and-Drop
Question: Place the steps for performing an escharotomy in the correct order:
A) Administer analgesia
B) Cleanse the area with antiseptic
C) Make longitudinal incisions through eschar
D) Monitor for bleeding
E) Apply sterile dressings
Answer: A, B, C, D, E
, Rationale: Analgesia is given first for pain control, followed by cleansing to maintain
sterility, incisions to relieve compartment syndrome, monitoring for bleeding, and
applying dressings to protect the wound.
5. NGN Case Study - Bow-Tie
Question: A client with severe burns to both lower extremities is pending an
escharotomy and reports shortness of breath. Complete the bow-tie diagram.
o Actions: Administer oxygen, notify provider, prepare for escharotomy.
o Monitor: Respiratory rate, oxygen saturation, circulation in extremities.
o Complications: Compartment syndrome, respiratory distress, infection.
Rationale: Shortness of breath suggests possible airway compromise or
circulatory impairment. Oxygen and provider notification address urgent needs,
while monitoring prevents complications like compartment syndrome.
6. Multiple-Choice
Question: A nurse is caring for a client with a myocardial infarction (MI). Which
medication should be administered first?
A) Metoprolol
B) Aspirin
C) Morphine
D) Heparin
Answer: B) Aspirin
Rationale: Aspirin is given first in MI to inhibit platelet aggregation and reduce clot
growth, per the MONA protocol (Morphine, Oxygen, Nitroglycerin, Aspirin).
7. Multiple-Response
Question: A nurse is assessing a client with heart failure. Which findings indicate
worsening condition? (Select all that apply.)
A) Crackles in lung bases
B) Weight gain of 3 lb in 24 hours
C) Heart rate of 80 bpm
D) Peripheral edema
Answers: A, B, D
Rationale: Crackles, rapid weight gain, and edema indicate fluid overload, a sign of
worsening heart failure. A heart rate of 80 bpm is normal.
8. Multiple-Choice
Question: A nurse is caring for a client with a chest tube for a pneumothorax. Which
finding requires immediate action?
A) Tidaling in the water seal chamber
B) Continuous bubbling in the water seal chamber
C) Drainage of 50 mL/hour
D) Suction set at -20 cm H2O
Answer: B) Continuous bubbling in the water seal chamber
Rationale: Continuous bubbling indicates an air leak, a complication requiring
immediate investigation. Tidaling and drainage are expected, and -20 cm H2O is a
standard suction setting.
9. Fill-in-the-Blank
Question: A client with COPD has a PaCO2 of __________ mm Hg, indicating
hypercapnia.
Verified Questions and Rationales
(2024/2025 Edition)
1. Multiple-Choice
Question: A nurse is caring for a client admitted to the emergency department with
extensive partial and full-thickness burns to the head, neck, and chest. What is the
priority nursing action?
A) Administer IV fluids
B) Assess airway patency
C) Apply topical antibiotics
D) Insert a urinary catheter
Answer: B) Assess airway patency
Rationale: Burns to the head, neck, and chest can compromise the airway due to swelling
or inhalation injury. Airway assessment is the priority to ensure breathing. Fluid
resuscitation follows after airway and breathing are secured.
2. Multiple-Response
Question: A nurse is planning care for a client with a 30% total body surface area
(TBSA) burn. Which interventions should be included? (Select all that apply.)
A) Monitor for hypothermia
B) Administer tetanus prophylaxis
C) Provide high-protein, high-calorie diet
D) Restrict fluids to prevent edema
Answers: A, B, C
Rationale: Burns increase hypothermia risk due to skin loss, require tetanus prophylaxis
for wound infection prevention, and necessitate a high-protein, high-calorie diet for
healing. Fluid restriction is inappropriate as burns require aggressive fluid resuscitation.
3. Fill-in-the-Blank
Question: A client with a 40% TBSA burn requires fluid resuscitation using the Parkland
formula. The client weighs 70 kg. The nurse should administer __________ mL of
lactated Ringer’s in the first 8 hours.
Answer: 5,600
Rationale: The Parkland formula is 4 mL × TBSA (%) × weight (kg). For 40% TBSA
and 70 kg: 4 × 40 × 70 = 11,200 mL total, with half (5,600 mL) given in the first 8 hours.
4. Drag-and-Drop
Question: Place the steps for performing an escharotomy in the correct order:
A) Administer analgesia
B) Cleanse the area with antiseptic
C) Make longitudinal incisions through eschar
D) Monitor for bleeding
E) Apply sterile dressings
Answer: A, B, C, D, E
, Rationale: Analgesia is given first for pain control, followed by cleansing to maintain
sterility, incisions to relieve compartment syndrome, monitoring for bleeding, and
applying dressings to protect the wound.
5. NGN Case Study - Bow-Tie
Question: A client with severe burns to both lower extremities is pending an
escharotomy and reports shortness of breath. Complete the bow-tie diagram.
o Actions: Administer oxygen, notify provider, prepare for escharotomy.
o Monitor: Respiratory rate, oxygen saturation, circulation in extremities.
o Complications: Compartment syndrome, respiratory distress, infection.
Rationale: Shortness of breath suggests possible airway compromise or
circulatory impairment. Oxygen and provider notification address urgent needs,
while monitoring prevents complications like compartment syndrome.
6. Multiple-Choice
Question: A nurse is caring for a client with a myocardial infarction (MI). Which
medication should be administered first?
A) Metoprolol
B) Aspirin
C) Morphine
D) Heparin
Answer: B) Aspirin
Rationale: Aspirin is given first in MI to inhibit platelet aggregation and reduce clot
growth, per the MONA protocol (Morphine, Oxygen, Nitroglycerin, Aspirin).
7. Multiple-Response
Question: A nurse is assessing a client with heart failure. Which findings indicate
worsening condition? (Select all that apply.)
A) Crackles in lung bases
B) Weight gain of 3 lb in 24 hours
C) Heart rate of 80 bpm
D) Peripheral edema
Answers: A, B, D
Rationale: Crackles, rapid weight gain, and edema indicate fluid overload, a sign of
worsening heart failure. A heart rate of 80 bpm is normal.
8. Multiple-Choice
Question: A nurse is caring for a client with a chest tube for a pneumothorax. Which
finding requires immediate action?
A) Tidaling in the water seal chamber
B) Continuous bubbling in the water seal chamber
C) Drainage of 50 mL/hour
D) Suction set at -20 cm H2O
Answer: B) Continuous bubbling in the water seal chamber
Rationale: Continuous bubbling indicates an air leak, a complication requiring
immediate investigation. Tidaling and drainage are expected, and -20 cm H2O is a
standard suction setting.
9. Fill-in-the-Blank
Question: A client with COPD has a PaCO2 of __________ mm Hg, indicating
hypercapnia.
