ATI RN
ATI Detailed Answer Key Medical Surgical Questions
Question 1 of 5
A break in sterile technique occurs during surgery when the scrub nurse touches
Correct Answer: A
Rationale: In surgical settings, maintaining sterile technique is crucial to prevent infections. In this scenario, the correct answer is option A) the mask with sterile gloved hands. This action is considered a break in sterile technique because the mask is considered a sterile field and touching it with gloved hands can introduce potential contaminants. Option B) touching the gown at chest level with sterile gloved hands is incorrect as the gown is part of the sterile field and should not be touched during surgery. Option C) touching the drape at the incision site with sterile gloved hands is incorrect because the drape covers the surgical site and must remain sterile to prevent infection. Option D) touching the lower arm to the instruments on the instrument tray is incorrect as it introduces the risk of contaminating the instruments which are meant to be sterile. Educationally, understanding and adhering to sterile technique principles are fundamental for healthcare professionals working in surgical environments to ensure patient safety and prevent surgical site infections. It is essential to continuously reinforce these principles through training and practice to maintain aseptic conditions during surgical procedures.
Question 2 of 5
To prevent agitation during the patient's recovery from anesthesia, when should the nurse begin orientation explanations?
Correct Answer: B
Rationale: In this scenario, the correct answer is B) When the patient first arrives in the PACU. This timing is crucial for several reasons. When a patient is recovering from anesthesia, they may be disoriented, confused, or agitated due to the effects of the anesthesia wearing off. Providing orientation explanations upon arrival in the Post-Anesthesia Care Unit (PACU) allows the nurse to establish a baseline understanding for the patient before they become fully awake and potentially agitated. This early orientation helps reduce anxiety, fear, and agitation by preparing the patient for their surroundings and the recovery process. Option A) When the patient is awake may not be the best choice because by that time, the patient might already be feeling disoriented and anxious, which could lead to agitation. Option C) When the patient becomes agitated or frightened is reactive rather than proactive and may not effectively prevent agitation. Option D) When the patient can be aroused and recognizes where he or she is might be too late as the patient could already be in a state of distress before reaching that point. Educationally, this question highlights the importance of proactive nursing interventions in preventing patient agitation and promoting a smooth recovery process. It emphasizes the significance of timely communication and patient-centered care in the post-anesthesia setting, where patients are vulnerable and require support to navigate the transition from sedation to wakefulness.
Question 3 of 5
Priority Decision: A patient in the PACU has emergence delirium manifested by agitation and thrashing. What should the nurse assess for first in the patient?
Correct Answer: A
Rationale: In this scenario, the correct answer is option A) Hypoxemia. When a patient in the PACU exhibits emergence delirium with agitation and thrashing, the nurse's first priority should be to assess for hypoxemia. Hypoxemia can lead to altered mental status, including delirium, so addressing this issue is crucial to ensure the patient's safety and well-being. The nurse should assess the patient's oxygen saturation levels, respiratory rate, and lung sounds to determine if there is any impairment in oxygenation. Option B) Neurologic injury is not the most immediate concern in this situation. While neurologic injury is always a potential risk in any patient, the patient's current symptoms are more indicative of hypoxemia rather than neurologic injury. Option C) Distended bladder and option D) Cardiac dysrhythmias are also important considerations in postoperative patients, but they are not the priority in a patient presenting with emergence delirium and agitation. These issues can be assessed once the patient's oxygenation status has been addressed. In an educational context, this question highlights the importance of prioritizing patient assessments based on the presenting symptoms and potential complications. It emphasizes the need for nurses to quickly identify and address critical issues to ensure patient safety and optimal outcomes. Understanding the rationale behind prioritizing assessments can help nurses make informed clinical decisions in fast-paced and high-stress environments like the PACU.
Question 4 of 5
Which tubes drain gastric contents (select all that apply)?
Correct Answer: D
Rationale: In this question, the correct answer is option D) Indwelling catheter. An indwelling catheter, also known as a Salem Sump or Levin tube, is specifically designed to drain gastric contents. It is inserted through the nose or mouth, down the esophagus, and into the stomach to remove stomach contents, provide decompression, or administer enteral feedings. Option A) T-tube is incorrect as it is typically used for bile drainage after gallbladder surgery, not gastric drainage. Option B) Hemovac is incorrect as it is a closed wound drainage system used to remove blood and other fluids from a surgical site, not gastric contents. Option C) Nasogastric tube is incorrect in this context as it is used for various purposes such as decompression, feeding, or medication administration, but it is not specifically designed to drain gastric contents like an indwelling catheter. Educationally, understanding the purpose and appropriate use of different types of tubes in clinical practice is crucial for nursing students and healthcare professionals. It is essential to differentiate between various tubes to provide safe and effective patient care based on their specific indications and functions. This knowledge helps in preventing complications and ensuring proper treatment interventions for patients requiring tube management.
Question 5 of 5
During the rehabilitative phase following his cerebrovascular accident, Mr. K. is taught measures to relieve or prevent constipation. Which of these statements indicates that Mr. K. needs further health teaching?
Correct Answer: C
Rationale: In this scenario, option C, "I don't drink fluids after 4 P.M.," indicates that Mr. K. needs further health teaching regarding measures to relieve or prevent constipation. Proper hydration is essential for maintaining bowel regularity, and limiting fluids in the evening can contribute to constipation. Option A, "I eat whole-wheat bread with my meals," and option B, "I eat fruit three times a day," are both appropriate strategies to prevent constipation as they provide dietary fiber which aids in digestion and bowel movements. Option D, "I don't like to take enemas," is not directly related to preventive measures for constipation. Enemas are typically used as a last resort for severe constipation and are not a primary method for managing bowel regularity. From an educational perspective, this question highlights the importance of holistic patient education during the rehabilitative phase post-cerebrovascular accident. Nurses must ensure that patients receive comprehensive instructions on managing various aspects of their health, including strategies to prevent constipation to promote overall well-being and recovery.