ATI RN
ATI RN Adult Medical Surgical 2023 Questions Correct Answers Questions
Extract:
Question 1 of 5
A nurse is analyzing the ABG results of a client who is in respiratory acidosis. Which of the following mechanisms should the nurse identify as responsible for this acid-base imbalance?
Correct Answer: A
Rationale: The correct answer is A: Retention of carbon dioxide. In respiratory acidosis, there is an excess of carbon dioxide (CO2) in the blood, leading to a decrease in pH. This imbalance occurs when the lungs are unable to eliminate enough CO2 through respiration, causing it to accumulate in the bloodstream. This excess CO2 combines with water in the blood to form carbonic acid, leading to acidosis.
Choices B, C, and D are incorrect as they do not directly relate to the accumulation of CO2 in respiratory acidosis. Loss of bicarbonate (
B) would lead to metabolic acidosis, excessive vomiting (
C) would cause metabolic alkalosis, and hyperventilation (
D) would actually help in decreasing CO2 levels, which is not the case in respiratory acidosis.
Question 2 of 5
A nurse is caring for a client who has emphysema. Which of the following interventions should the nurse include in the client's plan of care?
Correct Answer: D
Rationale: The correct answer is D. Teaching the client a breathing exercise with a longer inhalation phase helps improve lung capacity and strengthen respiratory muscles, which are essential for clients with emphysema. This intervention can help the client breathe more effectively and reduce shortness of breath. Option A is incorrect because limiting fluid intake is not a standard intervention for emphysema. Option B is incorrect as administering oxygen is not specific to improving lung function. Option C is incorrect as incentive spirometry is more effective if done for longer durations.
Question 3 of 5
A nurse is providing teaching to a client who is scheduled for a bronchoscopy. Which of the following statements should the nurse include in the teaching?
Correct Answer: A
Rationale:
Correct Answer: A
Rationale: The nurse should include the statement "You will not be able to eat or drink after the procedure until you are able to cough" because it is essential for the client's safety to prevent aspiration. After a bronchoscopy, the client may have an impaired gag reflex from the procedure, increasing the risk of choking.
Therefore, it is crucial to wait until the gag reflex returns before eating or drinking. This statement emphasizes the importance of airway protection post-procedure.
Summary:
B: Incorrect - Breathing during a bronchoscopy is usually done through the mouth.
C: Incorrect - Bronchoscopy is uncomfortable but not typically painful due to sedation.
D: Incorrect - Sedation is commonly used during bronchoscopy to ensure client comfort.
E: Incorrect - Bed rest after a bronchoscopy is not typically necessary unless complications arise.
Question 4 of 5
A nurse is analyzing the ABG results of a client who is in respiratory acidosis. Which of the following mechanisms should the nurse identify as responsible for this acid-base imbalance?
Correct Answer: A
Rationale: The correct answer is A: Retention of carbon dioxide. In respiratory acidosis, there is an excess of carbon dioxide (CO2) in the blood, leading to a decrease in pH. This imbalance occurs when the lungs are unable to eliminate enough CO2 through respiration, causing it to accumulate in the bloodstream. This excess CO2 combines with water in the blood to form carbonic acid, leading to acidosis.
Choices B, C, and D are incorrect as they do not directly relate to the accumulation of CO2 in respiratory acidosis. Loss of bicarbonate (
B) would lead to metabolic acidosis, excessive vomiting (
C) would cause metabolic alkalosis, and hyperventilation (
D) would actually help in decreasing CO2 levels, which is not the case in respiratory acidosis.
Question 5 of 5
A nurse is caring for a client who had a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care?
Correct Answer: B
Rationale: The correct answer is B: Turn the client by log rolling with a turning sheet. After a lumbar laminectomy, it is essential to prevent twisting or bending at the waist to avoid damaging the surgical site. Log rolling with a turning sheet maintains proper alignment of the spine. Encouraging independent ambulation (
A) may put strain on the surgical area. Positioning in a high Fowler's position (
C) may increase pressure on the surgical site. Applying a heating pad (
D) can lead to increased inflammation and potential burns.