ATI RN
ATI Nurs285 Med Surg Exam Questions
Extract:
Question 1 of 5
The nurse is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly?
Correct Answer: B
Rationale: Fluctuation of the fluid level within the water seal chamber (tidaling) indicates proper chest tube function, reflecting changes in intrapleural pressure during respiration. Continuous bubbling suggests an air leak, and absence of fluid or equal drainage amounts are not specific indicators of functionality.
Question 2 of 5
A nurse is caring for a client diagnosed with a fractured left tibia and fibula. Which data should the nurse report to the healthcare provider immediately?
Correct Answer: C
Rationale: The absence of pedal pulses and increasing pain suggest compromised circulation, possibly due to compartment syndrome, a medical emergency requiring immediate intervention. Other findings are expected or less urgent.
Question 3 of 5
A nurse is assessing the respiratory status of a client who has suffered a fractured rib. Which observation, if made by the nurse, would not be directly related to the fractured rib?
Correct Answer: A
Rationale: Pleural effusion on the unaffected side is not directly related to a fractured rib and is likely caused by another condition, such as infection or malignancy. Shallow breathing, guarding, and localized pain are expected with rib fractures.
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
A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds?
Correct Answer: B
Rationale: Wheezes are high-pitched, continuous sounds heard primarily during expiration due to narrowed airways, characteristic of asthma. Rhonchi are low-pitched, stridor is inspiratory, and crackles are discontinuous.