ATI RN
ATI Detailed Answer Key Medical Surgical Questions
Question 1 of 5
A client in an emergency department has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Administer oxygen via nasal cannula. In a client with a sucking chest wound, the priority is to ensure adequate oxygenation due to potential respiratory compromise. Administering oxygen via nasal cannula will help improve oxygenation and support the client's respiratory function. This action takes precedence over other interventions as hypoxia can lead to further deterioration. A: Raising the foot of the bed to a 90° angle is not indicated in this situation as it does not address the immediate need for oxygenation. B: Removing the dressing to inspect the wound can worsen the condition by disrupting any seals in place to prevent air from entering the chest cavity. C: Preparing to insert a central line is not the priority in this situation as the client's respiratory status needs to be stabilized first.
Question 2 of 5
A post-anesthesia care unit nurse is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give the highest priority to?
Correct Answer: A
Rationale: The correct answer is A: Arterial blood gases. This is the highest priority assessment for a client post-thoracotomy and lobectomy as it helps monitor the client's oxygenation status and acid-base balance, crucial after thoracic surgery. ABGs provide immediate information on the client's respiratory function, detecting any respiratory complications early on. The other options, B: Urinary output, C: Chest tube drainage, and D: Pain level, are important assessments but not as critical as monitoring the client's oxygenation status post-thoracic surgery. Urinary output is important for renal function, chest tube drainage for monitoring for any bleeding or air leakage, and pain level for comfort, but none of these directly assess the client's respiratory status and potential complications.
Question 3 of 5
A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?
Correct Answer: D
Rationale: Step 1: The client with gastroenteritis is at risk for fluid volume deficit due to vomiting and diarrhea, leading to loss of fluids. Step 2: Febrile state increases fluid loss through sweating. Step 3: Combining gastroenteritis and fever exacerbates fluid loss, making this client at high risk. Step 4: Clients A, B, and C do not have immediate factors contributing to fluid volume deficit as evident from their conditions. Summary: Client D is at risk due to gastroenteritis and fever causing significant fluid loss. Clients A, B, and C do not have conditions directly leading to fluid deficit.
Question 4 of 5
A healthcare professional is assessing a client who has a fracture of the femur. Vital signs are obtained on admission and again in 2 hours. Which of the following changes in assessment should indicate to the healthcare professional that the client could be developing a serious complication?
Correct Answer: A
Rationale: Step 1: Increased respiratory rate from 18 to 44/min indicates potential respiratory distress, a serious complication post-fracture. Step 2: Rapid breathing can signify hypoxemia, pulmonary embolism, or infection, requiring immediate intervention. Step 3: Increased oral temperature and blood pressure within normal range are not as critical as respiratory distress. Step 4: A slight increase in heart rate is common after a fracture and not indicative of a serious complication.
Question 5 of 5
A client is postoperative, and a nurse is developing a plan of care. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?
Correct Answer: C
Rationale: The correct answer is C: Encourage the use of an incentive spirometer. This intervention helps prevent pulmonary complications by promoting deep breathing and preventing atelectasis. A: Range-of-motion exercises do not directly prevent pulmonary complications. B: Placing suction equipment is important but does not prevent pulmonary complications. D: Administering an expectorant helps with mucus clearance but does not prevent pulmonary complications as effectively as using an incentive spirometer.