ATI RN
ATI Detailed Answer Key Medical Surgical Questions
Question 1 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 2 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 3 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 4 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.
Question 5 of 5
A client is 12 hours postoperative and has a chest tube to a disposable water-seal drainage system with suction. The healthcare provider should intervene for which of the following observations?
Correct Answer: B
Rationale: The correct answer is B: Continuous bubbling in the water-seal chamber. Continuous bubbling in the water-seal chamber indicates an air leak in the system, which can lead to lung collapse. The water-seal chamber should have intermittent bubbling during exhalation but should not bubble continuously. Constant bubbling in the suction-control chamber (A) is expected and indicates proper suction is being applied. Bloody drainage in the collection chamber (C) is common in the immediate postoperative period. Fluid-level fluctuations in the water-seal chamber (D) can be normal due to changes in intrathoracic pressure.