ATI RN
ATI Detailed Answer Key Medical Surgical Questions
Question 1 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 2 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.
Question 3 of 5
A client with a tracheostomy is being cared for by a nurse. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge?
Correct Answer: C
Rationale: The correct answer is C: Performing the procedure independently. This indicates readiness for discharge as it demonstrates the partner's ability to safely and effectively perform suctioning without direct supervision. Attending a class (A) and asking relevant questions (D) are important but do not necessarily indicate competence in performing the procedure. Verbally explaining the steps (B) shows understanding but does not confirm practical skill.
Question 4 of 5
A client developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Decreased serum calcium level. In fat embolism syndrome (FES), fat globules enter the bloodstream and can cause hypocalcemia due to the formation of calcium soaps. This can lead to symptoms such as confusion and tetany. The other choices are incorrect because in FES, there is no direct impact on serum lipids or ESR. Platelet count may be normal or decreased due to the consumption of platelets in the process.
Question 5 of 5
A client is unconscious with a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?
Correct Answer: C
Rationale: The correct answer is C: Cheyne-Stokes respirations. This breathing pattern is characterized by alternating periods of deep, rapid breathing (hyperventilation) followed by periods of apnea. This pattern is often seen in clients with neurological or cardiac conditions. Kussmaul respirations (A) are deep and rapid breathing associated with metabolic acidosis. Apneustic respirations (B) are characterized by prolonged inhalation and short, insufficient exhalation. Stridor (D) is a high-pitched, noisy breathing sound caused by obstructed air flow in the upper airway, not associated with the described breathing pattern.