ATI ADVANCED MED SURG PROCTORED EXAM 2023 WITH
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GLASGOW COMA SCALE REAL EXAM WITH ACCURATE
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DETAILED ANSWERS/A+ GRADE ss ss ss
1. A nurse in a burn treatment center is caring for a client who is admitted
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s with severe burns to both lowerextremities andispending anescharotomy.
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The client’s spouse asks the nurse what the procedure entails. Which of the
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following
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nursing statements is appropriate? ss ss ss
a. “largeincisions will be made inthe escharto improve circulation”
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b. “ I can call the doctor back here if you want me to”
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c. “apiece of skin will be removedand graftedover the burnedarea”
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d. “dead tissue willbe surgically removed” ss ss s ss ss
2. Anurseismonitoringthe fluidreplacemento fa client who hassustained burns.
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Which of the following fluids is used in the first 24 hours following a burn
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injury?
ss
a. 5%dextrose in water s ss ss
b. 5%dextrosein normal saline s s ss ss
c. normal saline ss
d. lactated ringers ss
3. A nurse is caring for a client who has full-thickness burns all
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over 75% of his body. Which of the following methods is
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appropriate to accurately monitor the cardiovascular system?
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a. auscultate cuff blood pressure ss ss ss
b. palpatepulse pressure ss
c. obtain a central venous pressure vv ss ss ss
d. monitor the pulmonary artery pressure ss ss ss ss
4. A nurse is assessing the depth and extent of a client who has severe burns to the
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face, neck, and upper extremities. Which of the following factors is the first priority
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when assessing the severity of the burn?
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a. Age of the client ss s ss
b. Associated medical history ss ss
c. Locationof the burn s ss ss
d. Cause of the burn ss ss ss
5. A client arrives at the emergency dept following an explosion at the
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chemical plant. Hehasdeeppartial andfull-thickness chemical burns over
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, more than25% of his body surface area. What is the nurse’s priority
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intervention?
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a. Initiate fluid resuscitation
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b. Medication for pain
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c. Administer antibiotics
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, d. Maintaina patent airway s ss ss
6. A nurse is caring for a client who came the emergency dept
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reporting chest pain. The provider suspects a myocardial infarction. While
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waiting for the laboratory to report the client’s troponin levels, the client
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asks what this blood test will show.
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Thenurse shouldexplain that troponin is
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a. Anenzyme that indicates damage tobrain, heart, and skeletal ss vv ss ss ss ss ss
muscle tissues
ss ss
b. Aproteinwhoselevels reflect the risk for coronary arterydisease s ss ss ss ss ss ss s
c. A heart muscle protein that appears in the bloodstream when
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there is damage to the heart
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d. A protein that helps transport oxygen throughout the body
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7. Anurse is assessing aclient whohasdisseminated intravascular coagulation
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(DIC). Which of the following should the nurse expect in the
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findings?
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a. Excessive thrombosis and bleeding ss ss ss
b. Progressive increase in platelet production ss ss ss ss
c. Immediate sodium and fluid retention ss ss ss ss
d. Increased clotting factors ss ss
8. Anurse is about to administer warfarin (Coumadin) toaclient whohasatrial
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fibrillation. When the client asks what his medication will do, which of the
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following is an appropriate nursing response?
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a. It helps convert atrial fibrillation to sinus rhythm
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b. Isdissolves clots in the bloodstream
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c. It slows the response ofthe ventricles to the fast atrial impulses
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d. It prevents strokes in clients who have atrial fibrillation
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9. Anurseina cardiaccareunitiscaringfor a client with acuteheartfailure.Which of
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the following findings should the nurse expect?
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a. Decreased brain natriuretic peptide (BNP) ss ss ss ss
b. Elevated central venous pressure (CVP) ss ss ss ss
c. Decreased pulmonary pressure ss ss
d. Increases urinary output ss ss
10. A client comes into the ED reporting nausea and vomiting that
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worsens when lying down and without relief from antacids. The provider
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suspects acute pancreatitis. Which ofthe following labtest results shouldthe nurse
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expect to see if the client has acute pancreatitis?
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a. Decreased WBC ss
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Pica
ss ss ss ss ss ss ss
GLASGOW COMA SCALE REAL EXAM WITH ACCURATE
ss ss ss ss ss ss ss
DETAILED ANSWERS/A+ GRADE ss ss ss
1. A nurse in a burn treatment center is caring for a client who is admitted
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
s with severe burns to both lowerextremities andispending anescharotomy.
s s s ss ss ss ss ss ss
The client’s spouse asks the nurse what the procedure entails. Which of the
ss ss ss ss ss ss ss ss ss ss ss ss ss
following
ss
nursing statements is appropriate? ss ss ss
a. “largeincisions will be made inthe escharto improve circulation”
s ss ss ss ss ss ss ss
b. “ I can call the doctor back here if you want me to”
ss ss ss ss ss ss ss ss ss ss ss ss
c. “apiece of skin will be removedand graftedover the burnedarea”
ss ss ss ss ss s ss s s ss s
d. “dead tissue willbe surgically removed” ss ss s ss ss
2. Anurseismonitoringthe fluidreplacemento fa client who hassustained burns.
s s s ss s s s vv s s ss
Which of the following fluids is used in the first 24 hours following a burn
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
injury?
ss
a. 5%dextrose in water s ss ss
b. 5%dextrosein normal saline s s ss ss
c. normal saline ss
d. lactated ringers ss
3. A nurse is caring for a client who has full-thickness burns all
s s s s s s s s s s s s s s s s s s s s s s
over 75% of his body. Which of the following methods is
s s s s s s ss s s s s s s s s s s s s s s
appropriate to accurately monitor the cardiovascular system?
s s s s s s ss ss ss ss
a. auscultate cuff blood pressure ss ss ss
b. palpatepulse pressure ss
c. obtain a central venous pressure vv ss ss ss
d. monitor the pulmonary artery pressure ss ss ss ss
4. A nurse is assessing the depth and extent of a client who has severe burns to the
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
face, neck, and upper extremities. Which of the following factors is the first priority
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
when assessing the severity of the burn?
ss ss ss ss ss ss ss
a. Age of the client ss s ss
b. Associated medical history ss ss
c. Locationof the burn s ss ss
d. Cause of the burn ss ss ss
5. A client arrives at the emergency dept following an explosion at the
ss ss ss ss ss ss ss ss ss ss ss
chemical plant. Hehasdeeppartial andfull-thickness chemical burns over
s s s s ss ss ss ss ss
Downloaded by Panda s s s s
Pica
, more than25% of his body surface area. What is the nurse’s priority
ss ss s s ss ss ss ss ss ss ss ss ss ss
intervention?
ss
a. Initiate fluid resuscitation
ss ss
b. Medication for pain
ss ss
c. Administer antibiotics
ss
Downloaded by Panda
s s s s
Pica
, d. Maintaina patent airway s ss ss
6. A nurse is caring for a client who came the emergency dept
s s s s s s s s s s s s s s s s s s s s s s
reporting chest pain. The provider suspects a myocardial infarction. While
s s s s ss ss ss ss ss ss ss ss
waiting for the laboratory to report the client’s troponin levels, the client
ss ss ss ss s s s s s s s s s s s s s s s s
asks what this blood test will show.
s s s s s s s s ss ss ss
Thenurse shouldexplain that troponin is
s ss s ss vv ss
a. Anenzyme that indicates damage tobrain, heart, and skeletal ss vv ss ss ss ss ss
muscle tissues
ss ss
b. Aproteinwhoselevels reflect the risk for coronary arterydisease s ss ss ss ss ss ss s
c. A heart muscle protein that appears in the bloodstream when
ss s s ss s s ss s s ss s s ss
there is damage to the heart
ss ss ss ss ss ss
d. A protein that helps transport oxygen throughout the body
ss ss ss ss ss ss ss ss
7. Anurse is assessing aclient whohasdisseminated intravascular coagulation
ss ss ss ss ss ss
(DIC). Which of the following should the nurse expect in the
ss s s s s s s s s s s ss s s s s s s s s
findings?
s s
a. Excessive thrombosis and bleeding ss ss ss
b. Progressive increase in platelet production ss ss ss ss
c. Immediate sodium and fluid retention ss ss ss ss
d. Increased clotting factors ss ss
8. Anurse is about to administer warfarin (Coumadin) toaclient whohasatrial
ss ss vv ss ss ss ss ss
fibrillation. When the client asks what his medication will do, which of the
ss ss ss ss ss ss ss ss ss ss ss ss ss
following is an appropriate nursing response?
ss ss ss ss ss ss
a. It helps convert atrial fibrillation to sinus rhythm
ss ss ss ss ss ss ss
b. Isdissolves clots in the bloodstream
s ss ss ss ss
c. It slows the response ofthe ventricles to the fast atrial impulses
vv ss ss ss ss ss ss ss vv ss
d. It prevents strokes in clients who have atrial fibrillation
ss ss ss ss ss ss ss ss
9. Anurseina cardiaccareunitiscaringfor a client with acuteheartfailure.Which of
s s ss s s s s s ss vv ss s s s ss
the following findings should the nurse expect?
ss ss ss ss ss ss ss
a. Decreased brain natriuretic peptide (BNP) ss ss ss ss
b. Elevated central venous pressure (CVP) ss ss ss ss
c. Decreased pulmonary pressure ss ss
d. Increases urinary output ss ss
10. A client comes into the ED reporting nausea and vomiting that
s s s s s s s s s s s s s s s s s s s s
worsens when lying down and without relief from antacids. The provider
s s ss ss ss ss ss ss ss ss ss ss
suspects acute pancreatitis. Which ofthe following labtest results shouldthe nurse
ss ss s s ss s s ss ss ss ss s ss
expect to see if the client has acute pancreatitis?
ss ss s ss ss ss ss ss ss
a. Decreased WBC ss
Downloaded by Panda s s s s
Pica
