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 is experiencing an acute asthma attack. Which of the following should the nurse identify as a contributing factor to the client's manifestations?
Correct Answer: D
Rationale: The correct answer is D: Inability to exhale retained carbon dioxide. During an acute asthma attack, there is airway obstruction, leading to air trapping and difficulty exhaling. This causes retention of carbon dioxide, leading to respiratory acidosis. This acidosis can further worsen the bronchoconstriction and airway inflammation in asthma.
Choices A, B, and C do not directly contribute to the manifestations of an acute asthma attack. Suppressed bronchiolar inflammatory response (
A) and decreased responsiveness of airways to allergens (
B) would not cause the acute symptoms seen in an asthma attack. Acute loss of alveolar elasticity (
C) is not a primary contributing factor to the acute manifestations of asthma.
Question 2 of 5
A nurse is completing discharge teaching with a client who has a new diagnosis of AIDS. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: D
Rationale:
Correct
Answer: D
Rationale:
1. Using alcohol to wipe up areas soiled with body fluids helps to disinfect the surfaces, reducing the risk of infection spread.
2. Immediately disposing of the trash containing body fluids prevents further exposure to infectious materials.
3. This statement demonstrates understanding of infection control measures crucial for someone with AIDS.
Incorrect
Choices:
A: Increasing fresh fruits and vegetables is a healthy choice but not directly related to preventing infection spread in the context of AIDS.
B: Taking clothes to the dry cleaners for sterilization is unnecessary and does not address infection control.
C: Wearing gloves and washing hands when changing a cat's litter box is a good hygiene practice but not specific to preventing transmission of HIV.
Question 3 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 4 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 5 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.