ATI RN
ATI RN Adult Medical Surgical 2023 Questions Correct Answers Questions
Extract:
Question 1 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.
Question 2 of 5
A nurse is teaching a client about using a metered-dose rescue inhaler. Which of the following statements should the nurse include in the teaching?
Correct Answer: B
Rationale: The correct answer is B: "Exhale fully before bringing the inhaler to your lips." This statement is important because exhaling fully before inhaling the medication helps to ensure maximum delivery of the medication into the lungs. By exhaling fully, the client creates more space in the lungs for the medication to reach the lower airways effectively.
Choice A is incorrect because depressing the canister after inhaling would not allow the medication to reach the lungs.
Choice C is incorrect as peroxide is not recommended for cleaning inhaler mouthpieces.
Choice D is incorrect because shaking the inhaler before use is necessary to ensure proper mixing of the medication for effective delivery.
Question 3 of 5
A nurse is caring for a client who has a peripherally inserted central catheter (PICC) line in her left forearm. The client is receiving an antibiotic via intermittent IV bolus every 12 hr. Which of the following actions should the nurse take in managing the client's PICC line?
Correct Answer: D
Rationale:
Correct Answer: D - Flush the catheter with a 0.9% sodium chloride solution after each use.
Rationale: Flushing the catheter with 0.9% sodium chloride solution after each use helps prevent clot formation, maintains patency, and ensures proper functioning of the PICC line. This action also helps prevent infection and occlusions.
Incorrect
Choices:
A: Accessing the catheter using a non-coring needle is not necessary for routine care of a PICC line.
B: Changing the transparent membrane dressing daily may increase the risk of infection and disrupt the integrity of the dressing.
C: Maintaining a continuous IV infusion through the PICC line is not indicated for a client receiving intermittent IV bolus antibiotics.
E, F, G: No additional choices provided.
Question 4 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.
Question 5 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.