ATI RN
ATI Detailed Answer Key Medical Surgical Questions
Question 1 of 5
Priority Decision: The nurse prepares to interview a patient for a nursing history but finds the patient in obvious pain. Which action by the nurse is the best at this time?
Correct Answer: A
Rationale: The correct answer is 'Delay the interview until the patient is free of pain.' Pain can interfere with concentration and communication, making it difficult for the patient to provide accurate information. Delaying the interview ensures better quality data collection once the patient is comfortable.
Question 2 of 5
A client is scheduled for a pneumonectomy in the morning. The client has had a previous negative surgical experience, is talking rapidly, and has an increased pulse and respiratory rate. Nursing interventions for this client should include:
Correct Answer: A
Rationale: Providing an opportunity for an open discussion will help to clarify any misunderstandings about the surgery and gives the client a chance to verbalize any concerns about the surgery. Distractions will not alleviate the client's preoperative anxiety; it denies the anxiety the client is experiencing. Giving false assurance is not appropriate and it denies that anxiety is a normal response to the threat of surgery. Psychological responses are not directly related to the severity of the surgery; they are influenced by the client's experience.
Question 3 of 5
Priority Decision: The husband and daughter of a Hispanic woman dying from pancreatic cancer refuse to consider using hospice care. What is the first thing the nurse should do?
Correct Answer: A
Rationale: The nurse should assess their understanding of hospice care services to ensure they are making an informed decision based on accurate information rather than assumptions or cultural biases.
Question 4 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 5 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: An S3 heart sound indicates volume overload.