ATI RN
ATI Detailed Answer Key Medical Surgical Questions
Question 1 of 5
A client has returned from the surgical suite following surgery for a fractured mandible with intermaxillary fixation. Which of the following actions is the priority for the nurse to take?
Correct Answer: A
Rationale: The correct answer is A: Prevent aspiration. This is the priority because with intermaxillary fixation, the client is unable to open their mouth, increasing the risk of aspiration. Aspiration can lead to serious complications, such as pneumonia. Ensuring the client's airway is clear and they are able to breathe properly should be the top priority. Summary: - B: Ensuring adequate nutrition can be important, but preventing aspiration takes precedence. - C: Promoting oral hygiene is important but not as urgent as preventing aspiration. - D: Relieving the client's pain is essential, but ensuring their safety from aspiration is the priority.
Question 2 of 5
During an assessment, a client with a long history of smoking and suspected laryngeal cancer will most likely report which early manifestation?
Correct Answer: B
Rationale: The correct answer is B: Hoarseness. Hoarseness is a common early manifestation of laryngeal cancer due to vocal cord involvement. Smoking is a major risk factor for laryngeal cancer. Dysphagia (choice A) is more commonly associated with esophageal cancer. Dyspnea (choice C) is usually a late manifestation of laryngeal cancer when it causes airway obstruction. Weight loss (choice D) may occur later in the disease progression but is not typically an early sign. Thus, hoarseness is the most likely early manifestation due to its direct connection to the vocal cords and smoking history.
Question 3 of 5
While caring for a client with extensive partial and full-thickness burns of the head, neck, and chest, which risk should the nurse prioritize for assessment and intervention?
Correct Answer: A
Rationale: The correct answer is A: Airway obstruction. This should be prioritized because burns to the head, neck, and chest can lead to swelling and inflammation, potentially compromising the airway. Maintaining a clear airway is crucial for oxygenation and ventilation. If the airway becomes obstructed, it can quickly lead to respiratory distress or failure. Assessing for signs of airway compromise and intervening promptly is essential to prevent serious complications. Choices B, C, and D are incorrect because while infection, fluid imbalance, and paralytic ileus are also important considerations in burn care, they are not as immediately life-threatening as airway obstruction in this case. Infection can be managed with appropriate wound care, fluid imbalance can be addressed with fluid resuscitation, and paralytic ileus can be treated with medications and bowel management strategies.
Question 4 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 5 of 5
A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Check the tubing connections for leaks. 1. Slow, steady bubbling in the suction control chamber indicates an air leak in the system. 2. Checking the tubing connections for leaks is the appropriate action to identify and fix the issue. 3. This helps maintain the integrity of the closed chest drainage system and prevent complications. Other choices are incorrect: B: Checking the suction control outlet on the wall is not necessary as the issue is likely within the tubing system. C: Clamping the chest tube could lead to tension pneumothorax and is not recommended unless ordered by a physician. D: Continuing to monitor the client's respiratory status does not address the underlying problem of the air leak.