ATI RN
Adult Medical Surgical ATI Questions
Question 1 of 5
You are reviewing your client's understanding of the post-operative stapedectomy instructions that you gave several days ago. Which comment concerns you the most?
Correct Answer: C
Rationale: In this scenario, option C: "I can't wait to get back to my regular weightlifting class," is the most concerning comment regarding post-operative stapedectomy instructions. Engaging in weightlifting places significant strain on the body, including the head and neck, which can jeopardize the healing process and potentially lead to complications, such as dislodging the surgical site or causing bleeding. Option A, regarding swimming lessons in a couple of months, and option B, mentioning a long overseas flight in several weeks, are less concerning as long as the client follows proper precautions, such as avoiding water entry into the ear canal and using ear protection during air travel to prevent pressure changes. Option D, stating coughing with the mouth open, is also a concern post-stapedectomy as it can increase the risk of introducing infection into the surgical site. However, the risk is lower compared to the physical strain associated with weightlifting. From an educational perspective, it is crucial for clients to understand and adhere to post-operative instructions to promote optimal healing and prevent complications. Educators must emphasize the importance of avoiding activities that can jeopardize the surgical site integrity and overall recovery process. Clients should be encouraged to consult healthcare providers if they have any doubts or concerns about their post-operative instructions to ensure a smooth recovery.
Question 2 of 5
A client has a three-chamber closed chest tube system, and the water seal chamber rises with client inspiration. What action should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Continue to monitor the client. When the water seal chamber rises with client inspiration, it indicates normal functioning of the chest tube system, allowing air to exit the pleural space. Monitoring ensures proper chest tube function. Option B is incorrect because there is no indication of immediate need for healthcare provider notification. Option C is unnecessary as repositioning won't address the issue. Option D is incorrect and dangerous as clamping the chest tube can lead to tension pneumothorax.
Question 3 of 5
A client is 12 hours postoperative following colon resection. Which of the following interventions should the nurse include in the plan to reduce respiratory complications?
Correct Answer: D
Rationale: The correct answer is D because splinting the incision supports coughing, which helps clear secretions and prevents respiratory complications. It is essential postoperatively to prevent atelectasis and pneumonia. Using an incentive spirometer (A) aids in lung expansion but does not directly support coughing. Ambulation (B) promotes circulation but does not address respiratory concerns. Maintaining a supine position with an abdominal binder (C) may restrict diaphragmatic movement and increase the risk of respiratory complications.
Question 4 of 5
While caring for a client receiving positive-pressure mechanical ventilation, which intervention should the nurse NOT implement to prevent complications?
Correct Answer: D
Rationale: The correct answer is D. Repositioning the endotracheal tube to the opposite side of the mouth daily is not necessary and could potentially lead to complications such as accidental extubation or damage to the airway. A: Elevating the head of the bed helps prevent aspiration. B: Verifying ventilator settings daily ensures proper functioning. C: Administering pantoprazole helps prevent stress ulcers. In summary, D is incorrect because it is unnecessary and poses risks, while A, B, and C are important interventions to prevent complications associated with positive-pressure mechanical ventilation.
Question 5 of 5
When performing tracheostomy care, which intervention should the nurse implement?
Correct Answer: C
Rationale: The correct answer is C: Secure new tracheostomy ties before removing old ones. This is essential to ensure the patient's airway remains stable and secure during the procedure. By securing the new ties first, the tracheostomy tube will not accidentally dislodge or become displaced. A: Using aseptic technique is important but not the immediate priority in this situation. B: Cleaning the inner cannula is a routine part of tracheostomy care but not the primary intervention during tie change. D: Applying suction when inserting the catheter is incorrect as suctioning should be performed after securing the new ties to maintain airway patency.