ATI CUSTOM: AH2- FA25- Exam 2
Access The Exact Questions for ATI CUSTOM: AH2- FA25- Exam 2
💯 100% Pass Rate guaranteed
🗓️ Unlock for 1 Month
Rated 4.8/5 from over 1000+ reviews
- Unlimited Exact Practice Test Questions
- Trusted By 200 Million Students and Professors
Starting from
$30/month
What’s Included:
- Unlock 100 + Actual Exam Questions and Answers for ATI CUSTOM: AH2- FA25- Exam 2 on monthly basis
- Well-structured questions covering all topics, accompanied by organized images.
- Learn from mistakes with detailed answer explanations.
- Easy To understand explanations for all students.
Searching for the top learning material with real ATI CUSTOM: AH2- FA25- Exam 2 exam questions to prepare for your tests? Join our site to access the content
Free ATI CUSTOM: AH2- FA25- Exam 2 Questions
1. A client with a spinal cord injury was given IV dexamethasone (Decadron) after arriving in the emergency department. What assessment finding should the nurse attribute to the steroid medication?
- A. Lessen spinal shock
- B. Muscle spasms
- C. Urinary retention
- D. Paralysis
Explanation
A. Lessen spinal shock
Dexamethasone (Decadron) is a corticosteroid that reduces inflammation and edema around the spinal cord following injury. By minimizing swelling and secondary tissue damage, it can improve neurological function and lessen the severity of spinal shock. This results in better perfusion to the injured area and preservation of nerve function, reducing complications associated with cord compression.
Dexamethasone (Decadron) is a corticosteroid that reduces inflammation and edema around the spinal cord following injury. By minimizing swelling and secondary tissue damage, it can improve neurological function and lessen the severity of spinal shock. This results in better perfusion to the injured area and preservation of nerve function, reducing complications associated with cord compression.
2. When planning immediate care for a client with moderate burns, what interventions should the nurse anticipate providing? (Select all that apply.)
- A. Use of topical antibiotics on the wounds
- B. Application of ice packs to the burned areas
- C. Mechanical ventilation for severe respiratory deterioration
- D. Laboratory studies to determine fluid-volume status
- E. Administration of tetanus immunization
- F. Immediate IV access with Lactated Ringer’s solution
Explanation
A. Use of topical antibiotics on the wounds
Topical antimicrobials such as silver sulfadiazine or bacitracin are applied to reduce the risk of infection. The skin’s protective barrier is lost in burn injuries, so infection prevention is a top priority in initial wound care.
D. Laboratory studies to determine fluid-volume status
Burns cause massive fluid shifts and electrolyte imbalances. Labs such as hematocrit, electrolytes, and BUN/creatinine help guide fluid resuscitation and monitor the client’s response to treatment.
E. Administration of tetanus immunization
Burn wounds create an entry point for Clostridium tetani, so tetanus prophylaxis is part of standard burn management, especially if immunization status is uncertain or outdated.
F. Immediate IV access with Lactated Ringer’s solution
Lactated Ringer’s is the preferred fluid for burn resuscitation because it closely resembles extracellular fluid composition. Early IV access ensures rapid replacement of fluids to maintain perfusion and prevent hypovolemic shock.
Topical antimicrobials such as silver sulfadiazine or bacitracin are applied to reduce the risk of infection. The skin’s protective barrier is lost in burn injuries, so infection prevention is a top priority in initial wound care.
D. Laboratory studies to determine fluid-volume status
Burns cause massive fluid shifts and electrolyte imbalances. Labs such as hematocrit, electrolytes, and BUN/creatinine help guide fluid resuscitation and monitor the client’s response to treatment.
E. Administration of tetanus immunization
Burn wounds create an entry point for Clostridium tetani, so tetanus prophylaxis is part of standard burn management, especially if immunization status is uncertain or outdated.
F. Immediate IV access with Lactated Ringer’s solution
Lactated Ringer’s is the preferred fluid for burn resuscitation because it closely resembles extracellular fluid composition. Early IV access ensures rapid replacement of fluids to maintain perfusion and prevent hypovolemic shock.
3. A nurse is caring for a client who was involved in a motor vehicle accident. The client is alert and oriented and reports a loss of consciousness immediately after the accident. Which of the following additional manifestations should the nurse assess the client for? (Select All that Apply.)
- A. Pupillary dilation
- B. Persistent headache
- C. Presence of hand tremors
- D. Difficulty waking
- E. Foot drop
Explanation
A. Pupillary dilation
Unequal or dilated pupils may indicate increased intracranial pressure (ICP) or brain herniation from bleeding or swelling after head trauma. This is a neurological emergency that requires immediate assessment and provider notification.
B. Persistent headache
A continuous or worsening headache following a head injury suggests concussion or intracranial bleeding. This is a key symptom of post-concussion syndrome or a developing hematoma and must be closely monitored for changes in severity or frequency.
D. Difficulty waking
Difficulty arousing the client indicates decreasing level of consciousness and potential progression of intracranial pressure or hemorrhage. It is a critical early sign of neurologic deterioration requiring urgent evaluation.
Unequal or dilated pupils may indicate increased intracranial pressure (ICP) or brain herniation from bleeding or swelling after head trauma. This is a neurological emergency that requires immediate assessment and provider notification.
B. Persistent headache
A continuous or worsening headache following a head injury suggests concussion or intracranial bleeding. This is a key symptom of post-concussion syndrome or a developing hematoma and must be closely monitored for changes in severity or frequency.
D. Difficulty waking
Difficulty arousing the client indicates decreasing level of consciousness and potential progression of intracranial pressure or hemorrhage. It is a critical early sign of neurologic deterioration requiring urgent evaluation.
4. A nurse is teaching a group of nursing students about brain herniation. Which of the following interventions should the nurse include as a possible treatment for brain herniation?
- A. Reduce the temperature in the room
- B. Lower blood pressure
- C. Hyperventilate the client
- D. Decrease sedation
Explanation
C. Hyperventilate the client
Hyperventilation is used temporarily in the management of brain herniation to reduce intracranial pressure (ICP). By lowering the arterial carbon dioxide (PaCO₂) level, cerebral vasoconstriction occurs, which decreases cerebral blood flow and volume, thereby lowering ICP. This is an emergency measure used only short-term while definitive treatment, such as surgical decompression or osmotic therapy (e.g., mannitol), is initiated.
Hyperventilation is used temporarily in the management of brain herniation to reduce intracranial pressure (ICP). By lowering the arterial carbon dioxide (PaCO₂) level, cerebral vasoconstriction occurs, which decreases cerebral blood flow and volume, thereby lowering ICP. This is an emergency measure used only short-term while definitive treatment, such as surgical decompression or osmotic therapy (e.g., mannitol), is initiated.
5. A victim of a motor vehicle crash has an acute cervical spinal cord injury. Which problem should the nurse identify as the priority for this client?
- A. Changes in mobility
- B. Fluid maintenance
- C. Problems breathing and ventilation
- D. Altered blood flow
Explanation
C. Problems breathing and ventilation
An acute cervical spinal cord injury can impair the function of the phrenic nerve (C3–C5), which controls the diaphragm—the primary muscle of respiration. Injury at or above this level can cause respiratory muscle paralysis, leading to ineffective ventilation, hypoxia, or respiratory arrest. Therefore, airway and breathing management are the top priorities. The nurse should monitor oxygen saturation, assess for shallow or labored breathing, and be prepared for intubation or mechanical ventilation.
An acute cervical spinal cord injury can impair the function of the phrenic nerve (C3–C5), which controls the diaphragm—the primary muscle of respiration. Injury at or above this level can cause respiratory muscle paralysis, leading to ineffective ventilation, hypoxia, or respiratory arrest. Therefore, airway and breathing management are the top priorities. The nurse should monitor oxygen saturation, assess for shallow or labored breathing, and be prepared for intubation or mechanical ventilation.
6. Nurse's Notes
Postoperative day #1
0700
Client is alert and oriented x 3. Lung sounds diminished in the bases, no adventitious sounds noted. Oxygen saturation is 89% on room air. Denies shortness of breath. Bowel sounds active × 4, denies having a bowel movement since surgery. Client rates pain as a 10 on a 0-10 pain scale and reports morphine 5 mg IVP that was administered 30 minutes ago is not working. Left leg splint dry with old drainage noted. Left foot cool to touch with absent posterior tibial and dorsalis pedis pulses. Capillary refill to left foot toes greater than 2 seconds. Cyanosis noted to left leg. Client reports tingling to left foot toes. 2+ edema noted to left leg/foot.
Orders
Postoperative day #1
Vital signs every 4 hours
Obtain blood glucose before meals and at bedtime
Diet as tolerated
Oxygen per nasal cannula to maintain oxygen saturation above 95%
Physical therapy to evaluate
Morphine sulfate 2-10 mg every 2-4 hours prn pain
Humalog insulin subcutaneous (SQ) sliding scale for blood glucose
Blood glucose less than 80 notify the health care provider
Blood glucose 80 mg/dL to 150 mg/dL = 10 units
Blood glucose 151 mg/dL to 200 mg/dL = 15 units
Blood glucose 201 mg/dL to 250 mg/dL = 20 units
Blood glucose 251 mg/dL to 300 mg/dL = 25 units
Blood glucose 301 mg/dL to 350 mg/dL = 30 units
Blood glucose 351 mg/dL to 400 mg/dL = 35 units
Greater than 401 mg/dL notify the health care provider
Vital Signs
Postoperative day #1
0700
Temperature 37.5°C (99.5°F)
Pulse rate: 94 beats/min
Respiratory rate: 24 breaths/min
Blood pressure: 140/85 mmHg
Oxygen saturation: 95% on room air
Which intervention should the nurse anticipate the healthcare provider prescribing? Select all that apply.
Postoperative day #1
0700
Client is alert and oriented x 3. Lung sounds diminished in the bases, no adventitious sounds noted. Oxygen saturation is 89% on room air. Denies shortness of breath. Bowel sounds active × 4, denies having a bowel movement since surgery. Client rates pain as a 10 on a 0-10 pain scale and reports morphine 5 mg IVP that was administered 30 minutes ago is not working. Left leg splint dry with old drainage noted. Left foot cool to touch with absent posterior tibial and dorsalis pedis pulses. Capillary refill to left foot toes greater than 2 seconds. Cyanosis noted to left leg. Client reports tingling to left foot toes. 2+ edema noted to left leg/foot.
Orders
Postoperative day #1
Vital signs every 4 hours
Obtain blood glucose before meals and at bedtime
Diet as tolerated
Oxygen per nasal cannula to maintain oxygen saturation above 95%
Physical therapy to evaluate
Morphine sulfate 2-10 mg every 2-4 hours prn pain
Humalog insulin subcutaneous (SQ) sliding scale for blood glucose
Blood glucose less than 80 notify the health care provider
Blood glucose 80 mg/dL to 150 mg/dL = 10 units
Blood glucose 151 mg/dL to 200 mg/dL = 15 units
Blood glucose 201 mg/dL to 250 mg/dL = 20 units
Blood glucose 251 mg/dL to 300 mg/dL = 25 units
Blood glucose 301 mg/dL to 350 mg/dL = 30 units
Blood glucose 351 mg/dL to 400 mg/dL = 35 units
Greater than 401 mg/dL notify the health care provider
Vital Signs
Postoperative day #1
0700
Temperature 37.5°C (99.5°F)
Pulse rate: 94 beats/min
Respiratory rate: 24 breaths/min
Blood pressure: 140/85 mmHg
Oxygen saturation: 95% on room air
Which intervention should the nurse anticipate the healthcare provider prescribing? Select all that apply.
- A. Check blood glucose
- B. Obtain blood pressure
- C. Prepare for fasciotomy
- D. Apply elastic anti-embolism stockings
- E. Ambulate patient
- F. Elevate left leg
- G. Perform neurovascular assessment
- H. Remove leg splint
Explanation
C. Prepare for fasciotomy
The client’s findings—cool, cyanotic left foot with absent dorsalis pedis and posterior tibial pulses, delayed capillary refill, and tingling—indicate compartment syndrome, a surgical emergency. A fasciotomy is required to relieve pressure and restore perfusion, preventing irreversible ischemia and potential limb loss. Immediate preparation for fasciotomy aligns with emergent treatment to preserve tissue viability.
G. Perform neurovascular assessment
Performing frequent neurovascular checks (color, temperature, pulses, sensation, capillary refill, and movement) is vital for monitoring progression of compromised circulation. These assessments provide critical data to determine worsening ischemia or nerve compression, guiding timely intervention and communication with the healthcare provider.
The client’s findings—cool, cyanotic left foot with absent dorsalis pedis and posterior tibial pulses, delayed capillary refill, and tingling—indicate compartment syndrome, a surgical emergency. A fasciotomy is required to relieve pressure and restore perfusion, preventing irreversible ischemia and potential limb loss. Immediate preparation for fasciotomy aligns with emergent treatment to preserve tissue viability.
G. Perform neurovascular assessment
Performing frequent neurovascular checks (color, temperature, pulses, sensation, capillary refill, and movement) is vital for monitoring progression of compromised circulation. These assessments provide critical data to determine worsening ischemia or nerve compression, guiding timely intervention and communication with the healthcare provider.
7. Introductory Sentence: A nurse is caring for a client who has severe burns.
History and Physical:
0820:
20-year-old client presents to the emergency department with severe burns. Client is grimacing and rates pain as 5 on a scale of 0 to 10. Patent airway. No increased work of breathing.
Vital Signs
0820:
Blood pressure 140/80 mm Hg
Heart rate 110/min
Respiratory rate 25/min
SaO2 98% on room air
Temp 36.1° C (97° F)
Assessment
2030:
Client is screaming and crying in pain. Client reports pain as 10 on a scale of 0 to 10. Client is very anxious and is breathing rapidly. Patent airway. Lungs are clear to auscultation bilaterally.
Which of the following actions should the nurse take when caring for a client with severe burns? (Select all that apply.)
History and Physical:
0820:
20-year-old client presents to the emergency department with severe burns. Client is grimacing and rates pain as 5 on a scale of 0 to 10. Patent airway. No increased work of breathing.
Vital Signs
0820:
Blood pressure 140/80 mm Hg
Heart rate 110/min
Respiratory rate 25/min
SaO2 98% on room air
Temp 36.1° C (97° F)
Assessment
2030:
Client is screaming and crying in pain. Client reports pain as 10 on a scale of 0 to 10. Client is very anxious and is breathing rapidly. Patent airway. Lungs are clear to auscultation bilaterally.
Which of the following actions should the nurse take when caring for a client with severe burns? (Select all that apply.)
- A. Cool the burn with ice water
- B. Administer opioid analgesics
- C. Administer systemic antibiotics
- D. Administer IV fluids per Parkland formula
- E. Administer benzodiazepines for anxiety
Explanation
B. Administer opioid analgesics
Opioids (such as morphine or fentanyl) are the first-line treatment for severe burn pain, which is often intense and prolonged. Pain control is crucial to reduce physiologic stress, facilitate procedures, and improve comfort during resuscitation and wound care.
D. Administer IV fluids per Parkland formula
Fluid resuscitation using the Parkland formula (4 mL × %TBSA × body weight in kg) is essential to prevent hypovolemic shock due to massive capillary leakage following severe burns. Half the total volume is given in the first 8 hours, and the remainder over the next 16 hours.
E. Administer benzodiazepines for anxiety
Severe burns often cause extreme anxiety, agitation, and emotional distress. Benzodiazepines may be prescribed alongside opioids to reduce anxiety and improve comfort without worsening pain perception.
Opioids (such as morphine or fentanyl) are the first-line treatment for severe burn pain, which is often intense and prolonged. Pain control is crucial to reduce physiologic stress, facilitate procedures, and improve comfort during resuscitation and wound care.
D. Administer IV fluids per Parkland formula
Fluid resuscitation using the Parkland formula (4 mL × %TBSA × body weight in kg) is essential to prevent hypovolemic shock due to massive capillary leakage following severe burns. Half the total volume is given in the first 8 hours, and the remainder over the next 16 hours.
E. Administer benzodiazepines for anxiety
Severe burns often cause extreme anxiety, agitation, and emotional distress. Benzodiazepines may be prescribed alongside opioids to reduce anxiety and improve comfort without worsening pain perception.
8. A nurse admits a client who has a subarachnoid hemorrhage and increased intracranial pressure (ICP). Which of the following medications should the nurse expect to administer to decrease ICP?
- A. Dopamine
- B. Nicardipine
- C. Mannitol
- D. Phenytoin
Explanation
C. Mannitol
Mannitol is an osmotic diuretic used to decrease intracranial pressure by drawing fluid from cerebral tissues into the vascular space, where it is excreted by the kidneys. This reduces cerebral edema and improves cerebral perfusion pressure (CPP). The nurse should closely monitor serum osmolality, urine output, and electrolytes to prevent dehydration or renal injury during therapy.
Mannitol is an osmotic diuretic used to decrease intracranial pressure by drawing fluid from cerebral tissues into the vascular space, where it is excreted by the kidneys. This reduces cerebral edema and improves cerebral perfusion pressure (CPP). The nurse should closely monitor serum osmolality, urine output, and electrolytes to prevent dehydration or renal injury during therapy.
9. A nurse is providing care for a client who is at risk of cerebral aneurysm rupture. Which of the following interventions should the nurse include in the care plan?
- A. Reposition the client every shift.
- B. Keep lights turned to medium level in the evening.
- C. Administer hypotonic intravenous solutions.
- D. Maintain the head of the bed between 30° and 45°.
Explanation
D. Maintain the head of the bed between 30° and 45°.
Keeping the head of the bed elevated between 30° and 45° helps reduce intracranial pressure (ICP) and promote venous drainage from the brain. In a client at risk of cerebral aneurysm rupture, preventing increases in ICP is essential because elevated pressure can trigger aneurysm rupture, resulting in subarachnoid hemorrhage. This position also aids in maintaining adequate cerebral perfusion pressure (CPP) while minimizing the risk of sudden vascular stress.
Keeping the head of the bed elevated between 30° and 45° helps reduce intracranial pressure (ICP) and promote venous drainage from the brain. In a client at risk of cerebral aneurysm rupture, preventing increases in ICP is essential because elevated pressure can trigger aneurysm rupture, resulting in subarachnoid hemorrhage. This position also aids in maintaining adequate cerebral perfusion pressure (CPP) while minimizing the risk of sudden vascular stress.
10. A nurse is caring for a client in the intensive care unit who was admitted with severe head trauma and cerebral edema. The client opens their eyes spontaneously, is oriented, and obeys commands. Which of the following findings indicate the client is experiencing a decline in their condition when the patient is reassessed? (Select all that apply.)
- A. Client responds to name
- B. Eyes open to painful stimuli
- C. Client states day of the week
- D. Client is confused
- E. Client mumbles inappropriate words
- F. Eyes do not open to name
Explanation
B. Eyes open to painful stimuli
Initially, the client opened their eyes spontaneously—a Glasgow Coma Scale (GCS) score of 4 for eye response. Opening eyes only to pain indicates a decrease to a GCS of 2, showing neurologic deterioration and decreased responsiveness.
D. Client is confused
The client was initially oriented (GCS verbal score of 5). Confusion represents a drop to a verbal score of 4, meaning cognitive decline and worsening cerebral function due to increasing intracranial pressure.
E. Client mumbles inappropriate words
Inappropriate or incomprehensible speech indicates further decline in the verbal component of the GCS. This suggests disruption of higher brain centers and possible progression of cerebral edema or increased ICP.
F. Eyes do not open to name
Failure to respond to verbal stimulation indicates decreasing level of consciousness. This loss of responsiveness is consistent with worsening neurological status and must be reported immediately.
Initially, the client opened their eyes spontaneously—a Glasgow Coma Scale (GCS) score of 4 for eye response. Opening eyes only to pain indicates a decrease to a GCS of 2, showing neurologic deterioration and decreased responsiveness.
D. Client is confused
The client was initially oriented (GCS verbal score of 5). Confusion represents a drop to a verbal score of 4, meaning cognitive decline and worsening cerebral function due to increasing intracranial pressure.
E. Client mumbles inappropriate words
Inappropriate or incomprehensible speech indicates further decline in the verbal component of the GCS. This suggests disruption of higher brain centers and possible progression of cerebral edema or increased ICP.
F. Eyes do not open to name
Failure to respond to verbal stimulation indicates decreasing level of consciousness. This loss of responsiveness is consistent with worsening neurological status and must be reported immediately.
How to Order
1
Select Your Exam
Click on your desired exam to open its dedicated page with resources like practice questions, flashcards, and study guides.Choose what to focus on, Your selected exam is saved for quick access Once you log in.
2
Subscribe
Hit the Subscribe button on the platform. With your subscription, you will enjoy unlimited access to all practice questions and resources for a full 1-month period. After the month has elapsed, you can choose to resubscribe to continue benefiting from our comprehensive exam preparation tools and resources.
3
Pay and unlock the practice Questions
Once your payment is processed, you’ll immediately unlock access to all practice questions tailored to your selected exam for 1 month .