ATI RN
Adult Medical Surgical ATI Questions
Question 1 of 5
To prepare a patient on the unit for a bronchoscopic procedure, the medical-surgical nurse administers an IV sedative. The nurse then instructs the licensed practical nurse to
Correct Answer: D
Rationale: In this scenario, the correct answer is D) take the patient to the bathroom one more time. This action is crucial before a bronchoscopic procedure because the patient will be sedated, and it is important to ensure their comfort and safety during the procedure. By assisting the patient to the bathroom one more time, the nurse helps prevent any potential issues such as the patient needing to use the bathroom during the procedure, which could cause complications. Option A is incorrect because educating the patient about the procedure should ideally be done before administering the sedative, not after. Option B is incorrect because giving the patient small sips of water is typically not recommended before a bronchoscopic procedure due to the risk of aspiration. Option C is incorrect as while monitoring vital signs is important, ensuring the patient's comfort and safety by assisting them to the bathroom takes precedence in this situation. In an educational context, it is crucial for nurses to understand the sequence of actions required before a procedure to ensure patient safety and comfort. This scenario highlights the importance of thorough patient preparation and the prioritization of tasks based on patient needs and procedural requirements in a medical-surgical setting.
Question 2 of 5
When examining a patient who is paralyzed below the T4 level, the medical-surgical nurse expects to find
Correct Answer: C
Rationale: In a patient paralyzed below the T4 level, the correct expectation is independent use of upper extremities and efficient cough (Option C). This is because T4 is the level at which the intercostal muscles, responsible for breathing, are innervated. With paralysis below T4, the patient retains upper extremity function as the nerves supplying the upper limbs arise above this level. Additionally, an efficient cough is expected as the patient can still utilize their upper chest and abdominal muscles to generate the necessary force for coughing. Option A (flaccidity of the upper extremities) is incorrect as the paralysis is below T4, so upper extremity function is preserved. Option B (hyperreflexia and spasticity of the upper extremities) is incorrect because hyperreflexia and spasticity are more indicative of upper motor neuron lesions, not lower motor neuron lesions typically seen in spinal cord injuries. Option D (impaired diaphragmatic function requiring ventilator support) is incorrect as the diaphragm is innervated by nerves arising from C3-C5, unaffected by a T4 level injury. Understanding the expected findings in patients with specific spinal cord injuries is crucial for nurses caring for these individuals. It helps in anticipating complications, providing appropriate care, and promoting optimal patient outcomes.
Question 3 of 5
The nurse is caring for a client with acute pancreatitis. After pain management, which intervention should be included in the plan of care?
Correct Answer: A
Rationale: Rationale: The correct answer is A) Cough and deep breathe every 2 hours. This intervention is crucial for a client with acute pancreatitis because it helps prevent atelectasis by promoting lung expansion and increasing oxygenation. Clients with acute pancreatitis are at risk for respiratory complications due to the proximity of the pancreas to the diaphragm and the potential for inflammation to affect lung function. Therefore, maintaining respiratory function is a priority in their care. Option B) Place the client in contact isolation is incorrect because acute pancreatitis is not a contagious condition that requires isolation precautions. Isolating the client unnecessarily could lead to feelings of social isolation and impact their emotional well-being. Option C) Provide a diet high in protein is incorrect because during the acute phase of pancreatitis, the client should be on a clear liquid diet or NPO (nothing by mouth) to rest the pancreas and reduce pancreatic stimulation. Introducing a high-protein diet at this stage can exacerbate the condition. Option D) Institute seizure precautions is incorrect because seizures are not a common complication of acute pancreatitis. Instituting seizure precautions without a specific indication can lead to unnecessary restrictions on the client's mobility and autonomy. In an educational context, understanding the rationale behind each intervention is crucial for nurses caring for clients with acute pancreatitis. By prioritizing interventions based on the client's condition and needs, nurses can provide safe and effective care that promotes optimal outcomes for the client's health.
Question 4 of 5
The nurse is caring for a client with a sigmoid colostomy who requests assistance in removing the flatus from a 1 piece drainable ostomy pouch. Which is the correct intervention?
Correct Answer: B
Rationale: The correct intervention in this scenario is option B) Opening the bottom of the pouch, allowing the flatus to be expelled. This is the correct choice because opening the bottom of the pouch is the appropriate method to release flatus without compromising the integrity of the ostomy pouch or risking contamination. By opening the pouch, the flatus can be easily and safely expelled without causing any harm to the client or the pouch. Option A) Piercing the plastic of the ostomy pouch with a pin to vent the flatus is incorrect because it can introduce infection or damage the pouch, leading to leakage. Option C) Pulling the adhesive seal around the ostomy pouch to allow the flatus to escape is also incorrect as it can compromise the seal and lead to leakage. Option D) Assisting the client to ambulate to reduce the flatus in the pouch is incorrect as it does not address the immediate need to release the flatus from the pouch. In an educational context, it is essential for nurses to understand the proper care and management of ostomy pouches to ensure the comfort and well-being of clients with ostomies. Knowing the correct interventions for common issues like flatus management is crucial in providing effective and safe care to clients with ostomies.
Question 5 of 5
A client complaining of severe shortness of breath is diagnosed with congestive heart failure. The nurse observes a falling pulse oximetry. The client's color changes to gray and she expectorates large amounts of pink frothy sputum. The first action of the nurse would be which of the following?
Correct Answer: D
Rationale: Rationale: The correct answer is D) Administer oxygen. In a client with congestive heart failure experiencing severe shortness of breath, falling pulse oximetry, gray skin color, and pink frothy sputum, the priority is to address the impaired oxygenation by providing oxygen. Administering oxygen will help improve oxygen saturation levels and support the client's respiratory function, which is crucial in this emergent situation. Option A) Call the health care provider can delay immediate intervention. In a critical situation like this, the nurse must act promptly to stabilize the client's condition before seeking further orders. Option B) Check vital signs is important, but providing oxygen takes precedence in addressing the client's acute respiratory distress. Option C) Position in high Fowler's is a supportive measure but does not address the immediate need for oxygenation in a client with severe respiratory distress. In an educational context, this scenario emphasizes the importance of prioritizing interventions based on the client's condition. Nurses must quickly assess and intervene in acute situations to ensure the best outcomes for their patients. Understanding the critical nature of respiratory distress in clients with heart failure is essential for nurses working in medical-surgical settings.