ATI RN
ATI Detailed Answer Key Medical Surgical Questions
Question 1 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 2 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 3 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.
Question 4 of 5
A client underwent a total laryngectomy. Which of the following is the priority observation in the client's care?
Correct Answer: D
Rationale: The correct answer is D: Need for suctioning. After a laryngectomy, maintaining a clear airway is crucial to prevent aspiration and ensure proper oxygenation. Suctioning helps remove secretions and maintain airway patency. Monitoring for signs of respiratory distress is essential. A: Patency of the intravenous line is important but not the priority over airway management. B: Level of pain is important but not as critical as ensuring a clear airway. C: Integrity of the dressing is important for wound healing but does not directly impact airway patency.
Question 5 of 5
A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?
Correct Answer: B
Rationale: The correct answer is B: Inspect the mouth for signs of inhalation injuries. This is the priority action because inhalation injuries can be life-threatening due to airway compromise. The nurse should assess for soot in the mouth, facial burns, hoarseness, and difficulty breathing. This allows for prompt intervention if respiratory distress is present. A: Inserting an indwelling urinary catheter is not the priority as it does not address the immediate life-threatening issue. C: Administering pain medication is important but not the priority over assessing for inhalation injuries which could lead to respiratory distress. D: Drawing blood for a CBC count is not the priority as it does not address the immediate threat to the client's airway.