ATI CUSTOM: AH2- FA25- Exam 2
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Free ATI CUSTOM: AH2- FA25- Exam 2 Questions
A nurse is caring for a client during fluid resuscitation for burns. Which of the following are used to evaluate the success of fluid resuscitation? (Select all that apply.)
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Blood pressure
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Bowel sounds
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Level of consciousness
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Urine output
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Platelet count
Explanation
A stable or improving blood pressure indicates effective restoration of circulating volume and perfusion. Adequate systolic pressure (usually >90 mm Hg) suggests the cardiovascular system is responding to resuscitation efforts.
C. Level of consciousness
Improved mental status and orientation reflect adequate cerebral perfusion. Confusion, restlessness, or decreased responsiveness may indicate hypoperfusion or ongoing hypovolemia.
D. Urine output
Urine output is the most reliable indicator of adequate fluid resuscitation. A minimum of 0.5 mL/kg/hr (≈30 mL/hr in adults) shows effective renal perfusion and sufficient circulating volume.
A nurse is taking care of a client who has sustained a neurologic injury with increased intracranial pressure and decreased cerebral perfusion. Which of the following will keep cerebral perfusion pressure constant?
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Regulation of constriction and dilation of blood vessels in the brain
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Regulation of how much blood is pumped from the heart
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Regulation of catecholamines circulating throughout the body
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Regulation of the amount of carbon dioxide exhaled
Explanation
The brain maintains a constant cerebral perfusion pressure (CPP) through cerebral autoregulation, which involves the constriction and dilation of cerebral blood vessels. This mechanism ensures stable blood flow to the brain despite fluctuations in systemic blood pressure. When perfusion pressure drops, cerebral vessels dilate to increase blood flow; when pressure rises, they constrict to prevent damage. This intrinsic regulation is essential for maintaining adequate oxygen and nutrient delivery to brain tissue.
A nurse is caring for a group of critically ill clients. Which of the following clients are exhibiting potential manifestations of sepsis? (Select all that apply.)
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A client who has a temperature of 37.2°C (99°F) and a heart rate of 88/min
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A client who has a heart rate of 132/min and a respiratory rate of 30/min
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A client who has a decrease in level of consciousness and a heart rate greater than 130/min
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A client who has bradypnea and a white blood cell (WBC) count of 10,000 mm³ (5,000–10,000/mm³)
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A client who has a temperature of 36°C (96.8°F) and a respiratory rate of 16/min
Explanation
Tachycardia and tachypnea are early clinical indicators of sepsis. The body increases heart and respiratory rates in response to systemic infection and tissue hypoperfusion. A respiratory rate above 20/min and a heart rate above 90/min meet Systemic Inflammatory Response Syndrome (SIRS) criteria, which can progress to sepsis if untreated.
C. A client who has a decrease in level of consciousness and a heart rate greater than 130/min
A declining level of consciousness suggests inadequate cerebral perfusion due to poor oxygen delivery from circulatory dysfunction. Combined with significant tachycardia, this indicates systemic infection with organ dysfunction, a hallmark of severe sepsis or septic shock.
A nurse has received report on a client who has a basilar skull fracture. Which of the following findings should the nurse anticipate with this client?
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Chvostek's sign
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Pooling of blood and edema around the eyes
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Ability to recall how the injury occurred
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Bruising over the mastoid process
Explanation
Bruising over the mastoid process, known as Battle’s sign, is a hallmark indicator of a basilar skull fracture. This bruising occurs behind the ear due to blood leakage from a fracture in the temporal bone. It often appears several hours after injury and may be accompanied by raccoon eyes (periorbital ecchymosis) or cerebrospinal fluid (CSF) leakage from the nose or ears. These findings signal potential dural tears and risk for infection such as meningitis.
A nurse is caring for a client who experienced severe head trauma. The client's partner asks the nurse why they are concerned about the mean arterial pressure (MAP). The nurse should explain that MAP determines which of the following?
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The client’s intake and output needs
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Resorption of cerebrospinal fluid
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Cerebral blood flow
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Regulation of blood pressure
Explanation
Mean arterial pressure (MAP) is the average pressure in the arteries during one cardiac cycle and is a key determinant of cerebral perfusion pressure (CPP)—the force driving blood to the brain tissue. Adequate MAP ensures that oxygen and nutrients reach brain cells. If MAP falls too low, cerebral perfusion decreases, leading to ischemia and worsening brain injury. Maintaining optimal MAP is critical in clients with head trauma to prevent secondary brain damage.
A nurse is teaching a client who has a complete spinal cord injury about bowel and bladder management. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
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"To achieve a bowel movement, daily digital stimulation will need to be done."
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"Do not drink fluids excessively as this may cause diarrhea."
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"You will need to learn how to do self-intermittent catheterization to drain your bladder."
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"It will be necessary to take a stool softener to keep you from becoming constipated."
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"Suprapubic catheterization might have to be done if you are unable to catheterize yourself."
Explanation
Clients with complete spinal cord injuries lose voluntary control of bowel function. Digital stimulation or suppositories at consistent times each day help trigger reflex defecation and establish a regular bowel program.
C. "You will need to learn how to do self-intermittent catheterization to drain your bladder."
Neurogenic bladder is common after spinal cord injury. Intermittent catheterization every 4–6 hours helps prevent bladder overdistention, urinary retention, and infection while maintaining bladder health.
D. "It will be necessary to take a stool softener to keep you from becoming constipated."
Loss of bowel motility and decreased activity predispose clients to constipation. Stool softeners and adequate fiber and fluid intake help maintain bowel regularity and prevent impaction.
E. "Suprapubic catheterization might have to be done if you are unable to catheterize yourself."
If the client cannot safely or effectively perform self-catheterization, a suprapubic catheter provides a long-term alternative for bladder drainage and reduces the risk of urethral trauma and infection.
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?
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Reduce the temperature in the room
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Lower blood pressure
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Hyperventilate the client
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Decrease sedation
Explanation
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.
The nurse suspects that a client with a spinal cord injury is experiencing autonomic dysreflexia. Which finding will help the nurse determine the cause for this health problem? (Select all that apply.)
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Fecal impaction
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Kinked urinary catheter
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Pressure injury
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Decreased heart rate
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Urinary tract infection
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Profuse sweating
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Dry skin
Explanation
A fecal impaction is a common cause of autonomic dysreflexia because bowel distension stimulates the sympathetic nervous system below the injury level. This leads to an abrupt rise in blood pressure and other autonomic symptoms until the obstruction is relieved.
B. Kinked urinary catheter
A kinked or blocked catheter causes bladder distension, the most frequent trigger of autonomic dysreflexia. Stretching of the bladder wall stimulates sympathetic overactivity, causing severe hypertension, headache, and flushing until the obstruction is cleared.
C. Pressure injury
Pressure injuries or tight clothing can act as noxious stimuli below the level of injury, initiating the exaggerated sympathetic response characteristic of autonomic dysreflexia. Regular skin assessments and repositioning help prevent this trigger.
E. Urinary tract infection
A UTI causes irritation and inflammation of the bladder wall, triggering autonomic dysreflexia episodes. Monitoring for urinary symptoms and maintaining sterile catheterization technique are critical in preventing recurrence.
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?
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Dopamine
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Nicardipine
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Mannitol
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Phenytoin
Explanation
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.
A nurse is planning care for a client who has neurogenic shock following a spinal cord injury. Which of the following provider prescriptions should the nurse anticipate? (Select all that apply.)
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Lactated Ringer’s intravenous fluid
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Epinephrine
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Furosemide
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Metoprolol
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Dopamine
Explanation
In neurogenic shock, hypotension occurs due to massive vasodilation from loss of sympathetic tone. Isotonic IV fluids such as Lactated Ringer’s help restore intravascular volume and maintain tissue perfusion until vasopressors are effective.
B. Epinephrine
Epinephrine acts as a vasoconstrictor and cardiac stimulant, increasing blood pressure and heart rate by stimulating both alpha and beta adrenergic receptors. It supports perfusion and combats the severe hypotension and bradycardia characteristic of neurogenic shock.
E. Dopamine
Dopamine is a vasopressor and inotropic agent that improves cardiac output and renal perfusion. It is often used to maintain mean arterial pressure (MAP ≥ 65 mm Hg) in clients with neurogenic shock when fluids alone are insufficient.
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