ATI RN
ATI Detailed Answer Key Medical Surgical Questions
Question 1 of 5
A client has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?
Correct Answer: B
Rationale: The correct answer is B: Weakness. Myasthenia gravis is characterized by muscle weakness due to an autoimmune attack on neuromuscular junctions. Monitoring for weakness is essential to assess disease progression and response to treatment. Confusion (A) is not a typical manifestation of myasthenia gravis. Increased intracranial pressure (C) is more commonly associated with conditions like head trauma or brain tumors. Increased urinary output (D) is not directly related to myasthenia gravis and is more indicative of conditions affecting the kidneys or fluid balance.
Question 2 of 5
While caring for a client with extensive partial and full-thickness burns of the head, neck, and chest, which risk should the nurse prioritize for assessment and intervention?
Correct Answer: A
Rationale: The correct answer is A: Airway obstruction. This should be prioritized because burns to the head, neck, and chest can lead to swelling and inflammation, potentially compromising the airway. Maintaining a clear airway is crucial for oxygenation and ventilation. If the airway becomes obstructed, it can quickly lead to respiratory distress or failure. Assessing for signs of airway compromise and intervening promptly is essential to prevent serious complications. Choices B, C, and D are incorrect because while infection, fluid imbalance, and paralytic ileus are also important considerations in burn care, they are not as immediately life-threatening as airway obstruction in this case. Infection can be managed with appropriate wound care, fluid imbalance can be addressed with fluid resuscitation, and paralytic ileus can be treated with medications and bowel management strategies.
Question 3 of 5
A client with chronic obstructive pulmonary disease (COPD tells the nurse, 'I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up.' Which of the following actions should the nurse take to help this client with tenacious bronchial secretions?
Correct Answer: D
Rationale: The correct answer is D: Encouraging the client to drink 2 to 3 L of water daily. Increased fluid intake helps to thin out bronchial secretions, making them easier to cough up. Step-by-step rationale: 1. Increased water intake promotes hydration, which thins mucus in the airways. 2. Thinner mucus is easier to expectorate, aiding in clearing airway congestion. 3. Adequate hydration also helps to prevent dehydration, which can further thicken secretions. Summary: A: Maintaining a semi-Fowler's position may help with breathing comfort but does not directly address the issue of thick secretions. B: Administering oxygen is important for COPD patients but does not specifically target bronchial secretions. C: Selecting a low-salt diet is beneficial for managing fluid retention but does not directly address the issue of tenacious bronchial secretions.
Question 4 of 5
A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Check the tubing connections for leaks. 1. Slow, steady bubbling in the suction control chamber indicates an air leak in the system. 2. Checking the tubing connections for leaks is the appropriate action to identify and fix the issue. 3. This helps maintain the integrity of the closed chest drainage system and prevent complications. Other choices are incorrect: B: Checking the suction control outlet on the wall is not necessary as the issue is likely within the tubing system. C: Clamping the chest tube could lead to tension pneumothorax and is not recommended unless ordered by a physician. D: Continuing to monitor the client's respiratory status does not address the underlying problem of the air leak.
Question 5 of 5
A client is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?
Correct Answer: D
Rationale: The correct answer is D: Airway patency. Assessing airway patency is the priority in the immediate postoperative period following a laryngectomy to ensure the client's ability to breathe. If the airway is compromised, it can lead to life-threatening complications. Pain severity (A), wound drainage (B), and tissue integrity (C) are important assessments but are secondary to ensuring the client's airway is clear and functioning properly. Prioritizing airway patency allows for prompt intervention if any issues arise, ensuring the client's safety and optimal recovery.