ATI RN
ATI Nurs285 Med Surg Exam Questions
Extract:
Question 1 of 5
One hour after a left thoracotomy, a patient reports incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 50 mLs of bloody drainage, and the nurse observes fluctuation in the water seal chamber. Which action should the nurse take?
Correct Answer: A
Rationale: Administering pain medication is the priority to improve comfort and respiratory effort, as pain can impair deep breathing. The drainage and fluctuation are expected post-thoracotomy.
Question 2 of 5
A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?
Correct Answer: D
Rationale: Movement of the trachea toward the unaffected side indicates tension pneumothorax, a life-threatening condition requiring immediate provider notification and intervention.
Question 3 of 5
A nurse is caring for a client who is receiving heparin 3,800 units subcutaneous daily. Available is heparin 5,000 units/mL. How many mL should the nurse administer?
Correct Answer: B
Rationale: Using the proportion: 3,800 units / 5,000 units/mL = 0.76 mL, rounded to 0.8 mL to the nearest tenth.
Question 4 of 5
A nurse is caring for an adolescent client whose right leg is in Buck's traction. Which of the following interventions should the nurse implement to promote the client's mobility?
Correct Answer: D
Rationale: Isometric exercises of both legs maintain muscle strength without disrupting traction, promoting mobility safely.
Question 5 of 5
A patient who is experiencing an acute asthma attack is admitted to the emergency department. Which assessment should the nurse complete first?
Correct Answer: C
Rationale: Assessing lung sounds first provides critical information about airway obstruction severity, guiding immediate interventions for an acute asthma attack.