ATI RN
ATI RN Adult Medical Surgical 2023 Questions Correct Answers Questions
Extract:
Question 1 of 5
A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching?
Correct Answer: A
Rationale:
Correct
Answer: A. Hold breaths about 3 to 5 seconds before exhaling.
Rationale: Holding the breath for a few seconds after inhaling with an incentive spirometer helps to fully expand the lungs and improve lung function. This technique prevents air from escaping too quickly and allows for optimal oxygen absorption. It also encourages deep breathing, which is essential for clearing the airways and improving overall lung capacity.
Summary of other choices:
B: Exhaling slowly through pursed lips is a technique used in pursed lip breathing, not with an incentive spirometer.
C: The position of the mouthpiece is important for comfort but not directly related to using the incentive spirometer.
D: Placing hands on the upper abdomen during inhalation is not a recommended technique for using an incentive spirometer.
Question 2 of 5
A nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: B
Rationale: The correct answer is B: "I should expect less than 25 mL of secretions per day in the drainage devices." This demonstrates an understanding of the need to monitor drainage postoperatively. Excessive drainage can indicate complications like infection or bleeding.
A: Performing strength-building exercises with a 15-pound weight is contraindicated postoperatively as it can strain the surgical site.
C: Waiting 2 months before adding saline to the expander is incorrect. Saline can be added gradually postoperatively.
D: Keeping the left arm flexed at the elbow is not recommended as it can lead to stiffness and limited range of motion.
Question 3 of 5
A nurse is caring for a client who is experiencing diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse?
Correct Answer: D
Rationale: The correct answer is D: Administer 0.9% sodium chloride. The priority intervention in DKA is fluid resuscitation to correct dehydration and electrolyte imbalances. 0.9% sodium chloride helps restore intravascular volume and improves kidney perfusion. Checking potassium levels (
A) is important but can wait until after fluid resuscitation. Beginning bicarbonate infusion (
B) is not recommended as it can worsen acidosis. Initiating continuous IV insulin infusion (
C) is important but should follow fluid resuscitation. Administering 0.9% sodium chloride takes precedence in managing DKA.
Question 4 of 5
A nurse is assessing a client who has a pressure injury. Which of the following findings should the nurse expect as an indication the wound is healing?
Correct Answer: D
Rationale: The correct answer is D: Dark red granulation tissue. Granulation tissue is a sign of healing in a wound, indicating new blood vessels and collagen formation. Dark red color indicates good blood supply. A: Firm wound tissue can indicate infection or inadequate healing. B: Dry brown eschar is a sign of necrotic tissue, not healing. C: Light yellow exudate can indicate infection or inflammation.
Question 5 of 5
A nurse is providing instructions about foot care for a client who has peripheral arterial disease. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: A
Rationale: The correct answer is A because applying a lubricating lotion to the cracked areas on the soles of the feet helps prevent further skin breakdown and infection, which is crucial in peripheral arterial disease.
Choice B may improve circulation, but it does not address foot care directly.
Choice C can lead to burns or injury due to decreased sensation in peripheral arterial disease.
Choice D poses a risk of injury or infection due to the potential for skin damage while soaking the feet. Overall, choice A is the most appropriate for maintaining foot health in peripheral arterial disease.