ATI RN
ATI Detailed Answer Key Medical Surgical Questions
Question 1 of 5
A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates an understanding of the teaching?
Correct Answer: D
Rationale: The correct answer is D because losing weight can help reduce the severity and frequency of obstructive sleep apnea. Excess weight can lead to fat deposits around the upper airway, causing obstruction during sleep. By losing weight, the airway may become less obstructed, reducing apneic episodes. Choice A is incorrect because sleeping on the back can actually worsen sleep apnea by causing the tongue and soft tissues to block the airway. Choice B is incorrect because sleeping pills can relax the muscles in the airway, making it more likely for an individual with sleep apnea to experience episodes of apnea. Choice C is incorrect because while a humidifier can alleviate some symptoms like dryness, it does not directly address the underlying cause of obstructive sleep apnea related to obesity.
Question 2 of 5
While providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort, which of the following desired effects of medications should the nurse identify as most important for the client's recovery?
Correct Answer: B
Rationale: The correct answer is B because facilitating the client's deep breathing is crucial post-CABG surgery to prevent complications such as atelectasis and pneumonia. Deep breathing helps improve lung expansion and oxygenation, promoting healing and preventing respiratory issues. A: While decreasing anxiety is important for overall well-being, it is not directly related to the client's recovery post-CABG surgery. C: Enhancing sleep is beneficial for healing, but it is not as critical as ensuring proper respiratory function in the immediate postoperative period. D: While reducing blood pressure may be desirable in some cases, it is not the most important effect to focus on post-CABG surgery; maintaining adequate oxygenation through deep breathing takes precedence.
Question 3 of 5
When assessing a client with a pneumothorax and a chest tube, which finding should the nurse notify the provider about?
Correct Answer: A
Rationale: Step 1: Movement of the trachea toward the unaffected side indicates tension pneumothorax, a life-threatening condition requiring immediate intervention. Step 2: This finding can lead to compromised breathing and hemodynamic instability if not addressed promptly. Step 3: B: Bubbling in the water seal chamber with exhalation is expected in a properly functioning chest tube system. Step 4: C: Crepitus at the insertion site is common due to air entering subcutaneous tissue during tube placement and is not an urgent concern. Step 5: D: Eyelets not visible can indicate dislodgement but is not as critical as tracheal deviation in this scenario.
Question 4 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 5 of 5
While suctioning the endotracheal tube of a client on a ventilator, the nurse notices an increase in the client's heart rate from 86/min to 110/min, with irregularity. What should the nurse do next?
Correct Answer: D
Rationale: The correct answer is D: Perform pre-oxygenation prior to suctioning. In this scenario, the increase in heart rate and irregularity could be due to hypoxia resulting from suctioning. Pre-oxygenation helps to ensure adequate oxygenation before the procedure, preventing hypoxia-induced dysrhythmias. By providing oxygen before suctioning, the nurse can minimize the risk of further complications. Choice A (Obtain a cardiology consult) is incorrect because immediate action is required to address the potential hypoxia, which can be managed by pre-oxygenation. Choice B (Suction the client less frequently) is incorrect as it does not address the immediate concern of potential hypoxia leading to dysrhythmias. Choice C (Administer an antidysrhythmic medication) is incorrect as it is not the initial intervention needed in this situation; addressing the underlying cause of potential hypoxia is essential before considering antidysrhythmic medications.