ATI RN
Adult Medical Surgical ATI Questions
Question 1 of 5
A client has a three-chamber closed chest tube system, and the water seal chamber rises with client inspiration. What action should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Continue to monitor the client. When the water seal chamber rises with client inspiration, it indicates normal functioning of the chest tube system, allowing air to exit the pleural space. Monitoring ensures proper chest tube function. Option B is incorrect because there is no indication of immediate need for healthcare provider notification. Option C is unnecessary as repositioning won't address the issue. Option D is incorrect and dangerous as clamping the chest tube can lead to tension pneumothorax.
Question 2 of 5
A client is 12 hours postoperative following colon resection. Which of the following interventions should the nurse include in the plan to reduce respiratory complications?
Correct Answer: D
Rationale: The correct answer is D because splinting the incision supports coughing, which helps clear secretions and prevents respiratory complications. It is essential postoperatively to prevent atelectasis and pneumonia. Using an incentive spirometer (
A) aids in lung expansion but does not directly support coughing. Ambulation (
B) promotes circulation but does not address respiratory concerns. Maintaining a supine position with an abdominal binder (
C) may restrict diaphragmatic movement and increase the risk of respiratory complications.
Question 3 of 5
While caring for a client receiving positive-pressure mechanical ventilation, which intervention should the nurse NOT implement to prevent complications?
Correct Answer: D
Rationale: The correct answer is D. Repositioning the endotracheal tube to the opposite side of the mouth daily is not necessary and could potentially lead to complications such as accidental extubation or damage to the airway. A: Elevating the head of the bed helps prevent aspiration. B: Verifying ventilator settings daily ensures proper functioning. C: Administering pantoprazole helps prevent stress ulcers. In summary, D is incorrect because it is unnecessary and poses risks, while A, B, and C are important interventions to prevent complications associated with positive-pressure mechanical ventilation.
Question 4 of 5
When performing tracheostomy care, which intervention should the nurse implement?
Correct Answer: C
Rationale: The correct answer is C: Secure new tracheostomy ties before removing old ones. This is essential to ensure the patient's airway remains stable and secure during the procedure. By securing the new ties first, the tracheostomy tube will not accidentally dislodge or become displaced.
A: Using aseptic technique is important but not the immediate priority in this situation.
B: Cleaning the inner cannula is a routine part of tracheostomy care but not the primary intervention during tie change.
D: Applying suction when inserting the catheter is incorrect as suctioning should be performed after securing the new ties to maintain airway patency.
Question 5 of 5
A client is 1 day postoperative following a lobectomy with a chest tube drainage system in place. Which finding by the nurse indicates a need for intervention?
Correct Answer: D
Rationale: The correct answer is D: Development of subcutaneous emphysema. This finding indicates air leakage, which can lead to potential complications like tension pneumothorax. Subcutaneous emphysema is a serious concern that requires immediate intervention.
A: Chest tube eyelets not visible - This is not a concerning finding as long as the chest tube is properly secured and functioning.
B: Continuous bubbling in the suction control chamber - This can indicate proper functioning of the system.
C: Presence of tidal fluctuation in the water seal chamber - This indicates that the system is working correctly, with the water seal chamber fluctuating with the patient's breathing.