ATI RN
ATI RN Adult Medical Surgical 2023 Questions Correct Answers Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has a chest tube. The client asks why the fluid in the water-seal chamber rises and falls. Which of the following statements should the nurse make?
Correct Answer: A
Rationale: The correct answer is A: "Your breathing pattern causes this." The fluctuation in the fluid level of the water-seal chamber of a chest tube system is directly related to changes in intrathoracic pressure during breathing. As the client breathes in and out, the negative pressure in the pleural space increases and decreases, causing the fluid to rise and fall in the water-seal chamber. This movement is a normal physiological response and indicates proper functioning of the chest tube system.
Choices B, C, and D are incorrect because they do not accurately explain the reason for the fluid fluctuation in the water-seal chamber.
Choice B is incorrect as lung re-expansion does not directly cause the fluid movement.
Choice C is incorrect as high suction pressure does not cause this specific phenomenon.
Choice D is incorrect as fluid movement does not indicate an air leak.
Question 2 of 5
A nurse is caring for a group of clients who are 12 hr postoperative. The nurse should identify that the client who had which of the following procedures is at risk for developing fat embolism syndrome?
Correct Answer: C
Rationale: The correct answer is C: Internal fixation of a fractured hip. Fat embolism syndrome (FES) typically occurs in long bone fractures or orthopedic surgeries like hip fixation due to fat droplets entering the bloodstream. These fat droplets can travel to the lungs, brain, and other organs, causing respiratory distress, neurological symptoms, and petechial rash. In contrast, choices A, B, and D are not associated with a high risk of FES. Thyroidectomy involves removal of the thyroid gland, repair of torn rotator cuff involves shoulder surgery, and tympanoplasty involves repairing the eardrum, none of which typically lead to fat embolism.
Question 3 of 5
A nurse is providing teaching to a client who has neutropenia and is receiving chemotherapy. Which of the following client statements indicates an understanding of the teaching?
Correct Answer: A, C
Rationale:
Correct Answer: A, C
Rationale:
A: Avoiding crowds helps reduce the risk of exposure to infections, crucial for neutropenic clients.
C: Taking temperature daily allows early detection of fever, a sign of infection.
B: Weekly toothbrush washing does not directly impact infection risk.
D: Fresh fruits and vegetables are good for health but not specific to neutropenia management.
Question 4 of 5
A nurse is caring for a client who has skeletal traction applied to the left leg. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Provide the client with a trapeze bar. This is essential for the client in skeletal traction to independently move and reposition themselves safely without putting additional stress on the affected leg. Using elbows (
A) can disrupt the traction. Removing weights (
B) can lead to complications. Checking pressure points (
C) is important but not specific to this situation. The trapeze bar (
D) promotes client independence and safety.
Question 5 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.