ATI RN
ATI Medsurg Proctored Final Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Keep the drainage system below the level of the client's chest at all times. This is crucial because maintaining the drainage system below the chest level prevents backflow of air or fluid into the client's chest cavity, which can lead to complications like tension pneumothorax or fluid re-entering the pleural space. Clamping the chest tube can cause a build-up of pressure and should only be done in emergency situations. Removing the chest tube is unsafe and can lead to respiratory distress. Allowing the client to carry the drainage system can risk dislodging the tube or causing tension on the connections.
Therefore, the best option is to keep the drainage system below the chest level to ensure proper drainage and prevent complications.
Question 2 of 5
A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications should the nurse identify as most important for the client's recovery?
Correct Answer: A
Rationale: The correct answer is A: It facilitates the client's deep breathing. Postoperative clients following CABG surgery are at risk for developing atelectasis due to decreased lung expansion. Opioid medications can cause respiratory depression, leading to shallow breathing. By facilitating deep breathing, the nurse helps prevent atelectasis and promotes optimal oxygenation, aiding in the client's recovery.
Choices B, C, and D are incorrect as they are not directly related to the immediate physiological needs of a postoperative CABG client. Increasing appetite, promoting wound healing, and decreasing anxiety are important aspects of overall recovery but are not as critical as ensuring proper oxygenation and preventing respiratory complications in the immediate postoperative period.
Question 3 of 5
The nurse is caring for a postoperative client who has a chest tube connected to suction and a water-seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly?
Correct Answer: A
Rationale: Fluctuation (tidaling) in the water-seal chamber during inspiration and expiration indicates the chest tube is functioning properly.
Question 4 of 5
A nurse is caring for a client who was admitted with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Provide frequent oral and nares care. This is important because the Sengstaken-Blakemore tube can cause discomfort and irritation to the oral and nasal mucosa, leading to potential complications such as infection or pressure ulcers. Providing frequent oral and nares care helps prevent these complications and ensures the client's comfort.
Choice B is incorrect because monitoring oxygen levels is not directly related to the care of a client with a Sengstaken-Blakemore tube.
Choice C is incorrect because administering intravenous antibiotics is not a routine intervention for a client with a Sengstaken-Blakemore tube unless there is a specific indication for infection.
Choice D is incorrect because the Sengstaken-Blakemore tube should not be removed immediately after 24 hours. The timing of removal should be determined based on the client's condition and the healthcare provider's orders.
Question 5 of 5
A nurse evaluates a client's PSA lab results. An increase in PSA indicates what condition?
Correct Answer: B
Rationale: The correct answer is B: Prostatic cancer. PSA levels are commonly used as a marker for prostate cancer. Elevated PSA levels indicate an increased likelihood of prostate cancer. Benign prostatic hyperplasia (choice
A) is a non-cancerous condition that can also cause elevated PSA levels but is not indicative of cancer. Urinary tract infection (choice
C) and kidney stones (choice
D) do not directly affect PSA levels. The other choices (E, F, G) are not provided, but the key is to understand that an increase in PSA specifically points towards the possibility of prostatic cancer.