ATI RN
Adult Medical Surgical ATI
1. A client is being admitted to the surgical unit from the PACU following a cholecystectomy. Which of the following assessments is the nurse's priority?
- A. Bowel sounds
- B. Surgical dressing
- C. Temperature
- D. Oxygen saturation
Correct answer: D
Rationale: The priority assessment for a client being admitted to the surgical unit following a cholecystectomy is oxygen saturation. Monitoring oxygen saturation is crucial to ensure adequate oxygenation and ventilation, especially after surgery. Hypoxia can have serious consequences and needs to be promptly addressed. While assessing bowel sounds, surgical dressing, and temperature are important, oxygen saturation takes precedence in this situation.
2. A healthcare provider is preparing to admit a client to the PACU who received a competitive neuromuscular blocking agent. Which of the following items should the provider place at the client's bedside?
- A. Bag valve mask device
- B. Defibrillator machine
- C. Chest tube equipment
- D. Central venous catheter tray
Correct answer: A
Rationale: When a client receives a competitive neuromuscular blocking agent, it can lead to respiratory muscle paralysis. Placing a bag valve mask device at the client's bedside is crucial for providing immediate respiratory support in case of respiratory depression or failure. This device allows manual ventilation by squeezing the bag to deliver breaths to the client. The other options, such as a defibrillator machine, chest tube equipment, and central venous catheter tray, are not directly related to managing respiratory complications associated with neuromuscular blockade.
3. While caring for a client receiving positive-pressure mechanical ventilation, which intervention should the nurse NOT implement to prevent complications?
- A. Elevate the head of the bed to at least 30�.
- B. Verify the prescribed ventilator settings daily.
- C. Administer pantoprazole as prescribed.
- D. Reposition the endotracheal tube to the opposite side of the mouth daily.
Correct answer: D
Rationale: Repositioning the endotracheal tube to the opposite side of the mouth daily is not a standard practice and can increase the risk of complications, such as accidental extubation or damage to the airway. The endotracheal tube should remain in the initial correct position to ensure proper ventilation and prevent harm to the client. Elevating the head of the bed, verifying ventilator settings, and administering pantoprazole as prescribed are all appropriate interventions to prevent complications in a client receiving positive-pressure mechanical ventilation.
4. A client with tuberculosis is starting medication therapy with isoniazid, rifampin, and pyrazinamide. Which of the following instructions should the nurse include?
- A. Take isoniazid with an antacid.
- B. Provide a sputum specimen every 2 weeks to the clinic for testing.
- C. Expect your sputum cultures to be negative after 6 months of therapy.
- D. Drink at least 8 ounces of water when you take the pyrazinamide tablet.
Correct answer: D
Rationale: Pyrazinamide can cause gastrointestinal upset and is best taken with a full glass of water to minimize irritation to the stomach lining. This instruction helps reduce the risk of adverse effects associated with pyrazinamide. Options A and C are not directly related to the medication regimen for tuberculosis. While sputum testing is important, the frequency mentioned in option B is not required every two weeks.
5. A client had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?
- A. Poor impulse control
- B. Inability to discriminate words and letters
- C. Deficits in the right visual field
- D. Motor retardation
Correct answer: A
Rationale: A stroke affecting the right cerebral hemisphere can lead to poor impulse control due to the involvement of this area in regulating behavior and inhibiting impulses. Deficits in the right visual field are associated with stroke affecting the left cerebral hemisphere. Inability to discriminate words and letters may be seen in left cerebral hemisphere strokes. Motor retardation may be observed with strokes affecting motor areas in either hemisphere but is not the most specific finding related to a right cerebral hemisphere stroke.
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