ATI RN
ATI RN Adult Medical Surgical 2023 Questions Correct Answers Questions
Extract:
Question 1 of 5
A PACU nurse is monitoring the drainage from a client's NG tube following abdominal surgery. Which of the following findings in the first postoperative hour should the nurse report to the provider?
Correct Answer: A
Rationale: The correct answer is A: 100 mL of red drainage. Red drainage from an NG tube may indicate active bleeding, which is a concerning finding post-abdominal surgery. This could suggest a potential internal bleeding or vascular injury. The nurse should report this finding to the provider immediately for further evaluation and intervention.
The other choices are incorrect because:
B: 75 mL of greenish-yellow drainage - This could be indicative of bile drainage, which is expected after abdominal surgery.
C: 200 mL of brown drainage - Brown drainage is likely due to old blood or bile, which can be normal in the immediate postoperative period.
D: 150 mL of serosanguineous drainage - Serosanguineous drainage is a mixture of blood and clear fluid, which can be expected after surgery.
Therefore, the correct answer is A due to the potential seriousness of active bleeding indicated by red drainage.
Question 2 of 5
A nurse in the PACU is caring for a client. Which of the following assessments is the nurse's priority?
Correct Answer: D
Rationale: The correct answer is D: Respiratory status. In the PACU, ensuring adequate oxygenation and ventilation is crucial for the client's immediate postoperative recovery. Monitoring respiratory status helps prevent complications like hypoxia or respiratory distress. Assessing the airway, breathing rate, depth, and oxygen saturation takes precedence over other assessments. Level of consciousness (
A) is important but can be affected by respiratory issues. Surgical site (
B) assessment is important but not an immediate priority. Pain level (
C) is important but can be managed once respiratory status is stable. Summary: Respiratory status is the priority as it directly impacts the client's immediate well-being and recovery.
Question 3 of 5
A nurse is caring for a client who has oral achalasia, The nurse should ask the client which of the following questions to assess their ability to swallow?
Correct Answer: A
Rationale: The correct answer is A: "Do you feel like you have food stuck at the base of your throat?" This question is appropriate for assessing the client's ability to swallow because oral achalasia is a condition where the lower esophageal sphincter fails to relax, causing difficulty in passing food from the mouth to the esophagus. Asking about the sensation of food stuck in the throat helps to identify this symptom.
Choice B: "Do you have any feelings of fullness in the neck?" is incorrect because fullness in the neck is not a typical symptom of oral achalasia.
Choice C: "Do you feel any burning sensations in your throat?" is incorrect because burning sensations are more commonly associated with acid reflux or GERD, not specifically with oral achalasia.
Choice D: "Do you have any problems with pain while swallowing?" is incorrect as pain while swallowing is not a typical symptom of oral achalasia.
Therefore, the correct question to assess
Question 4 of 5
Which of the following findings should the nurse identify as a contraindication to receiving this alternative therapy?
Correct Answer: B
Rationale: The correct answer is B: Lymphedema. Lymphedema is a swelling caused by a lymphatic system blockage, which can be worsened by some alternative therapies. Headaches, mouth sores, and urticaria are symptoms that may not necessarily contraindicate alternative therapy. Lymphedema can cause complications if not managed properly, making it a clear contraindication.
Question 5 of 5
A nurse is teaching a client about using a metered-dose rescue inhaler. Which of the following statements should the nurse include in the teaching?
Correct Answer: B
Rationale: The correct answer is B: "Exhale fully before bringing the inhaler to your lips." This statement is important because exhaling fully before inhaling the medication helps to ensure maximum delivery of the medication into the lungs. By exhaling fully, the client creates more space in the lungs for the medication to reach the lower airways effectively.
Choice A is incorrect because depressing the canister after inhaling would not allow the medication to reach the lungs.
Choice C is incorrect as peroxide is not recommended for cleaning inhaler mouthpieces.
Choice D is incorrect because shaking the inhaler before use is necessary to ensure proper mixing of the medication for effective delivery.