ATI RN
ATI RN Adult Medical Surgical 2023 Questions Correct Answers Questions
Extract:
Question 1 of 5
A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching?
Correct Answer: A
Rationale:
Correct Answer: A. Hold breaths about 3 to 5 seconds before exhaling.
Rationale: Holding the breath for a few seconds after inhaling with an incentive spirometer helps to fully expand the lungs and improve lung function. This technique prevents air from escaping too quickly and allows for optimal oxygen absorption. It also encourages deep breathing, which is essential for clearing the airways and improving overall lung capacity.
Summary of other choices:
B: Exhaling slowly through pursed lips is a technique used in pursed lip breathing, not with an incentive spirometer.
C: The position of the mouthpiece is important for comfort but not directly related to using the incentive spirometer.
D: Placing hands on the upper abdomen during inhalation is not a recommended technique for using an incentive spirometer.
Question 2 of 5
A nurse is caring for a client who has tuberculosis. Which of the following precautions should the nurse implement for this client?
Correct Answer: B
Rationale: The correct answer is B: Airborne precautions. Tuberculosis is transmitted through the air via droplet nuclei. Implementing airborne precautions includes wearing an N95 respirator, placing the client in a negative pressure room, and ensuring proper ventilation. Standard precautions (
A) are for all clients, contact precautions (
C) are for direct contact with the client or their environment, and droplet precautions (
D) are for pathogens transmitted through respiratory droplets.
Therefore, implementing airborne precautions is crucial to prevent the spread of tuberculosis.
Question 3 of 5
A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes that the weights are resting on the floor. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Reapply the weights to ensure proper traction. When the weights are resting on the floor, it means that there is no longer effective traction on the affected limb.
To maintain proper skeletal traction, the weights should be suspended freely in the air. By reapplying the weights and ensuring they are hanging freely, the nurse can restore the necessary traction force to immobilize the fractured bone and facilitate healing. Removing a weight (choice
A) may compromise the traction. Tying knots in the ropes (choice
B) may alter the mechanics of the traction system. Increasing the elevation of the extremity (choice
C) does not address the issue of the weights resting on the floor.
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 assessing a client who is 24 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Maintain abduction of the affected extremity. After a total hip arthroplasty, maintaining abduction of the affected extremity helps prevent dislocation of the hip prosthesis. This position helps stabilize the hip joint and reduces the risk of complications. Option B (Position the client in high Fowler's position) is incorrect as it does not directly address the postoperative care specific to a total hip arthroplasty. Option C (Encourage the client to cross their legs at the ankles) is incorrect because crossing legs can create pressure on the hip joint and increase the risk of dislocation. Option D (Have the client bend forward at the waist while sitting) is incorrect as this could also increase the risk of hip dislocation.