ATI RN
ATI Detailed Answer Key Medical Surgical Questions
Question 1 of 5
In teaching parents to associate prevention with the lifestyle of their child with sickle cell disease, the nurse should emphasize that a priority for their child is to:
Correct Answer: D
Rationale: In teaching parents to associate prevention with the lifestyle of their child with sickle cell disease, emphasizing the priority of maintaining routine immunizations (Option D) is crucial. Sickle cell disease compromises the immune system, making individuals more susceptible to infections. By ensuring routine immunizations, the child is better protected against preventable diseases, reducing the risk of complications associated with sickle cell disease. Avoiding overheating during physical activities (Option A) is important in managing sickle cell disease to prevent a crisis, but routine immunizations take precedence in overall preventive care. Maintaining normal activity with some restrictions (Option B) is relevant but not as vital as ensuring immunizations for overall health. Being cautious of others with viruses or temperatures (Option C) is important but does not address the proactive preventive measure of routine immunizations. In an educational context, this rationale highlights the significance of preventive care in managing sickle cell disease. By prioritizing routine immunizations, parents can actively protect their child from potential health risks associated with the condition, promoting overall well-being and quality of life.
Question 2 of 5
In assessing the healing of a client's wound during a home visit, which of the following is the best indicator of good healing?
Correct Answer: C
Rationale: In assessing the healing of a client's wound during a home visit, the best indicator of good healing is reddened tissue (Option C). Reddened tissue indicates that there is adequate blood flow to the area, which is essential for the delivery of oxygen and nutrients necessary for wound healing. This redness is a sign of the inflammatory phase of healing, where the body is actively working to repair the damaged tissue. White patches (Option A) may indicate the presence of pus or infection, which is a sign of poor healing and requires further assessment and intervention. Green drainage (Option B) is often a sign of infection as well, suggesting the presence of bacteria in the wound that can impede the healing process. Eschar development (Option D) refers to the formation of a hard, blackened crust over a wound, which can hinder healing by preventing new tissue growth. Educationally, understanding these indicators of wound healing is crucial for healthcare providers to make informed decisions about wound care interventions. Teaching students to recognize these signs helps to ensure proper assessment and timely intervention to promote effective wound healing and prevent complications.
Question 3 of 5
A client develops volume overload from an IV that has infused too rapidly. What assessment would the nurse expect to find?
Correct Answer: A
Rationale: In this scenario, the correct answer is A) S3 heart sound. When a client develops volume overload from rapid IV infusion, their heart may become overwhelmed by the increased volume, leading to impaired ventricular filling and increased pressure in the heart chambers. This can result in the development of an S3 heart sound, also known as a ventricular gallop, which is an extra heart sound heard in early diastole. Option B) Thready pulse is incorrect because a thready pulse is typically associated with decreased volume or poor perfusion, not volume overload. Option C) Flattened neck veins is incorrect because in volume overload, the client is likely to exhibit distended neck veins due to increased venous return to the heart. Option D) Hypoventilation is incorrect as it is not directly related to volume overload. Hypoventilation refers to inadequate breathing, which can lead to increased carbon dioxide levels in the blood. Educationally, understanding the assessment findings associated with volume overload is crucial for nurses caring for patients receiving IV fluids. Recognizing the subtle signs such as an S3 heart sound can prompt early intervention to prevent complications like heart failure. This knowledge helps nurses provide safe and effective care, ensuring optimal patient outcomes.
Question 4 of 5
Stephen Douglas has been in an automobile accident. The most effective IV solution for a patient having hypovolemic shock would be:
Correct Answer: B
Rationale: Hypertonic IV fluids would be used to draw fluid off tissue in edematous situations such as third spacing. Isotonic solutions are used to increase intravascular volume, to increase perfusion of vital organs. Hypotonic fluids are used to rehydrate tissue in those with severe, or prolonged fluid deprivation. Colloids increase tonicity of intravascular fluids, pulling water into the vascular system from tissue.
Question 5 of 5
A 64-year-old male client is admitted to the hospital with benign prostatic hypertrophy (BPH). The client has a history of adult onset diabetes mellitus and hypertension. He is scheduled to undergo a resection of the prostate. The most serious symptom that may accompany BPH is:
Correct Answer: A
Rationale: Acute urinary retention is a symptom of BPH, is serious, and requires urgent medical attention. Hesitancy in starting urination is a symptom of BPH, but it is not serious or life-threatening. Increased frequency of urination is a symptom of BPH, but it is not serious or life-threatening. Decreased force of the urinary stream is due to an obstruction, but it is not serious or life-threatening.