ATI RN
ATI Capstone Adult Medical Surgical Assessment 1 Questions
Question 1 of 5
A nurse in a rural community center is providing education to a group of clients about first aid interventions for snake bites. Which of the following instructions should the nurse include in the teaching?
Correct Answer: B
Rationale: The correct answer is to immobilize the affected extremity with a splint. This helps to slow the spread of venom by limiting movement. Applying an ice pack directly to the affected area (Choice A) is not recommended for snake bites as it could exacerbate tissue damage. Placing a tourniquet above and below the affected area (Choice C) is also not advised as it can lead to further complications. Elevating the affected extremity (Choice D) is not recommended for snake bites; keeping it below the level of the heart is more appropriate to reduce venom spread.
Question 2 of 5
A nurse in an emergency department is caring for a client who has sustained multiple injuries. The nurse observes the client's thorax moving inward during inspiration and outward during expiration. The nurse should suspect which of the following injuries?
Correct Answer: A
Rationale: The correct answer is A: Flail chest. Flail chest results from multiple rib fractures, causing paradoxical chest movement where the injured part moves inward during inspiration and outward during expiration, interfering with ventilation. Choice B, Hemothorax, involves blood in the pleural cavity and does not typically cause paradoxical chest movement. Choice C, Pulmonary contusion, is a bruise to the lung tissue and does not present with paradoxical chest movement. Choice D, Pneumothorax, is the presence of air in the pleural space, leading to lung collapse, but it does not demonstrate paradoxical chest movement like in flail chest.
Question 3 of 5
A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and is receiving 3% sodium chloride via continuous IV. Which of the following laboratory findings should the nurse identify as an indication that the SIADH is resolving?
Correct Answer: A
Rationale: A urine specific gravity of 1.020 is within the expected reference range and indicates that the kidneys are appropriately concentrating urine, which is a sign that the syndrome of inappropriate antidiuretic hormone (SIADH) is resolving. A low sodium level (choice B) is associated with SIADH, so a sodium level of 119 mEq/L is not indicative of resolution. BUN (choice C) and calcium levels (choice D) are typically not directly related to SIADH resolution.
Question 4 of 5
A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should indicate to the nurse the need for immediate intervention?
Correct Answer: C
Rationale: The correct answer is C. The nurse should prioritize airway and breathing in a client with a traumatic brain injury. An increased respiratory rate may indicate CO2 retention, which could lead to increased intracranial pressure. Choice A, axillary temperature 37.2°C (99°F), is within normal range and does not indicate an immediate need for intervention. Choice B, apical pulse 100/min, is slightly elevated but not as critical as respiratory distress in this scenario. Choice D, blood pressure 140/84 mm Hg, is also within normal limits and does not require immediate intervention compared to the respiratory rate.
Question 5 of 5
A client has a right-sided pneumothorax, and a chest tube is inserted. Which finding indicates that the chest drainage system is functioning correctly?
Correct Answer: A
Rationale: In a chest drainage system, gentle bubbling in the suction chamber indicates proper functioning, showing that the system is connected and working effectively to remove air or fluid from the pleural space. Crepitus around the insertion site (Choice B) suggests subcutaneous emphysema, not chest tube functionality. Constant bubbling in the water seal chamber (Choice C) indicates an air leak. Absence of breath sounds on the right side (Choice D) is indicative of the pneumothorax, not the chest tube function.