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 caring for a client who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration?
Correct Answer: A
Rationale: The correct answer is A. The rise in the water seal chamber with client inspiration indicates that the chest tube system is functioning properly. This rise is expected as the negative pressure in the pleural space increases during inspiration, causing the water level to momentarily increase. It is important for the nurse to understand this physiological response and continue to monitor the client for any signs of respiratory distress. Notifying the healthcare provider immediately or increasing suction level is unnecessary and may disrupt the client's respiratory status. Repositioning the client is not indicated in this situation.
Question 3 of 5
A nurse is assessing a client's wound dressing and observes a watery red drainage. The nurse should document this drainage as which of the following?
Correct Answer: C
Rationale: The correct answer is C: Serosanguineous. This type of drainage is a mixture of clear (serous) and red (sanguineous) fluids, indicating a normal stage of wound healing. The clear fluid suggests minimal inflammation, while the red fluid indicates presence of blood. Serous drainage alone is typically clear and watery without any blood. Sanguineous drainage is bright red and indicates fresh blood. Purulent drainage is thick, opaque, and yellowish-green, suggestive of infection.
Therefore, in this scenario, the observation of watery red drainage best fits the description of serosanguineous drainage.
Question 4 of 5
A nurse is teaching a client about snacks that are appropriate on a low-fat, low-sodium, and low-cholesterol diet. Which of the following food choices by the client indicates the need for further teaching?
Correct Answer: A
Rationale: The correct answer is A: A slice of cheese. Cheese is high in fat, sodium, and cholesterol, making it unsuitable for a low-fat, low-sodium, and low-cholesterol diet. The client needs further teaching to understand that cheese does not align with their dietary restrictions. The other options (B, C,
D) are suitable choices for a low-fat, low-sodium, and low-cholesterol diet. Almonds are a source of healthy fats, a baked apple is low in fat and sodium, and carrot sticks with hummus are low in fat and cholesterol while providing fiber and nutrients. These options align with the client's dietary needs and do not require further teaching.
Question 5 of 5
A nurse is admitting a client who has a serum calcium level of 12.3 mg/dL and initiates cardiac monitoring. Which of the following findings should the nurse expect during the initial assessment?
Correct Answer: A
Rationale: The correct answer is A: Lethargy. A serum calcium level of 12.3 mg/dL indicates hypercalcemia. In hypercalcemia, calcium affects the central nervous system, leading to lethargy, weakness, and confusion. Lethargy is a common early symptom of hypercalcemia. Hypertension is not typically associated with hypercalcemia. Muscle spasms are more common in hypocalcemia. Severe agitation is not a typical manifestation of hypercalcemia.