ATI RN
ATI Nurs285 Med Surg Exam Questions
Extract:
Question 1 of 5
The nurse is caring for a client diagnosed with end-stage chronic obstructive pulmonary disease (COPD). Which of the following data warrants immediate intervention by the nurse?
Correct Answer: C
Rationale: A respiratory rate of 28 breaths per minute indicates tachypnea and potential respiratory distress, requiring immediate assessment. Other findings are common or acceptable in end-stage COPD.
Extract:
Medical History
Nurses' Notes
Vital Signs
Client reports an injury to their right ribs after falling 6 feet from a ladder. Client reports pain as 8 on a scale of 0 to 10 over the right lower rib cage with ecchymosis. Client is dyspneic and respirations are shallow. Client states, "It's hard for me to breathe."
Question 2 of 5
A nurse is reviewing the client's medical record. Which of the following prescriptions should the nurse anticipate for a client who has a pneumothorax? For each potential provider's prescription, click to specify if the potential prescription is anticipated, non-essential, or contraindicated for the client.
| Options | Anticipated | Non- essential | Contraindicated |
|---|---|---|---|
| Obtain intravenous access: Anticipated | |||
| Computed tomography (CT) of the chest: Anticipated | |||
| Thoracentesis: Non-essential | |||
| Obtain ABGs (Arterial Blood Gases): Anticipated | |||
| Pulmonary Function Tests (PFTs): Contraindicated | |||
| Prepare for insertion of a chest tube: Anticipated |
Correct Answer: A,B,D,F
Rationale: IV access, CT chest, ABGs, and chest tube insertion are anticipated for pneumothorax management. Thoracentesis is non-essential as it addresses fluid, not air. PFTs are contraindicated in acute settings.
Extract:
Question 3 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 4 of 5
A client had a right-sided chest tube inserted two hours ago for pneumothorax. Which action should the nurse implement if there is no fluctuation in the water seal compartment?
Correct Answer: A
Rationale: Lack of fluctuation in the water seal compartment may indicate kinks, obstructions, or lung re-expansion. The nurse should first check the chest tube system for issues before escalating or adjusting suction.
Question 5 of 5
Unlicensed assistive personnel (UAP) reports a client diagnosed with a fractured femur has 'fatty globules' floating in the urinal. Which intervention should the nurse implement first?
Correct Answer: C
Rationale: Assessing the client for dyspnea and altered mental status is the first priority because these are early indicators of fat embolism syndrome (FES), a serious complication of long bone fractures. Immediate assessment allows for early recognition and intervention to prevent further complications.