ATI RN
ATI RN Adult Medical Surgical 2023 Questions Correct Answers Questions
Extract:
Question 1 of 5
A nurse is caring for a client immediately following a lumbar puncture. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Instruct the client to lie flat. This is important to prevent post-lumbar puncture headache by promoting the closure of the dural puncture site. Lying flat helps reduce the risk of cerebrospinal fluid leakage and subsequent headache. Limiting fluid intake (
A) is not necessary post-lumbar puncture. Monitoring blood glucose (
B) is not directly related to lumbar puncture care. Expecting tingling in extremities (
C) is not a common post-lumbar puncture symptom.
Question 2 of 5
A nurse is planning care for a client who has a seizure disorder. Which of the following equipment should the nurse place in the client's room?
Correct Answer: D
Rationale: The correct answer is D: Oral airway. During a seizure, a client may experience difficulty breathing due to their airway being obstructed. Placing an oral airway helps maintain a clear airway, ensuring adequate oxygenation. NG tube (
A) is not relevant to managing seizures.
Tongue blade (
B) can cause injury during a seizure. Wrist restraints (
C) are not appropriate and can increase the risk of injury.
Question 3 of 5
A PACU nurse is monitoring the drainage from a client's NG tube following abdominal surgery. Which of the following findings in the first postoperative hour should the nurse report to the provider?
Correct Answer: A
Rationale: The correct answer is A: 100 mL of red drainage. Red drainage from an NG tube may indicate active bleeding, which is a concerning finding post-abdominal surgery. This could suggest a potential internal bleeding or vascular injury. The nurse should report this finding to the provider immediately for further evaluation and intervention.
The other choices are incorrect because:
B: 75 mL of greenish-yellow drainage - This could be indicative of bile drainage, which is expected after abdominal surgery.
C: 200 mL of brown drainage - Brown drainage is likely due to old blood or bile, which can be normal in the immediate postoperative period.
D: 150 mL of serosanguineous drainage - Serosanguineous drainage is a mixture of blood and clear fluid, which can be expected after surgery.
Therefore, the correct answer is A due to the potential seriousness of active bleeding indicated by red drainage.
Question 4 of 5
A nurse in the PACU is caring for a client. Which of the following assessments is the nurse's priority?
Correct Answer: D
Rationale: The correct answer is D: Respiratory status. In the PACU, ensuring adequate oxygenation and ventilation is crucial for the client's immediate postoperative recovery. Monitoring respiratory status helps prevent complications like hypoxia or respiratory distress. Assessing the airway, breathing rate, depth, and oxygen saturation takes precedence over other assessments. Level of consciousness (
A) is important but can be affected by respiratory issues. Surgical site (
B) assessment is important but not an immediate priority. Pain level (
C) is important but can be managed once respiratory status is stable. Summary: Respiratory status is the priority as it directly impacts the client's immediate well-being and recovery.
Question 5 of 5
A nurse is caring for a client who has oral achalasia, The nurse should ask the client which of the following questions to assess their ability to swallow?
Correct Answer: A
Rationale: The correct answer is A: "Do you feel like you have food stuck at the base of your throat?" This question is appropriate for assessing the client's ability to swallow because oral achalasia is a condition where the lower esophageal sphincter fails to relax, causing difficulty in passing food from the mouth to the esophagus. Asking about the sensation of food stuck in the throat helps to identify this symptom.
Choice B: "Do you have any feelings of fullness in the neck?" is incorrect because fullness in the neck is not a typical symptom of oral achalasia.
Choice C: "Do you feel any burning sensations in your throat?" is incorrect because burning sensations are more commonly associated with acid reflux or GERD, not specifically with oral achalasia.
Choice D: "Do you have any problems with pain while swallowing?" is incorrect as pain while swallowing is not a typical symptom of oral achalasia.
Therefore, the correct question to assess