ATI RN
ATI Detailed Answer Key Medical Surgical
1. While caring for a client with extensive partial and full-thickness burns of the head, neck, and chest, which risk should the nurse prioritize for assessment and intervention?
- A. Airway obstruction
- B. Infection
- C. Fluid imbalance
- D. Paralytic ileus
Correct answer: A
Rationale: When a client sustains burns to the head, neck, or chest, the risk of airway obstruction is a critical concern due to potential swelling, inflammation, or inhalation injury. Any compromise to the airway can lead to severe respiratory distress or failure. Early recognition and intervention to maintain a clear airway are essential to prevent life-threatening complications in burn patients.
2. When assessing a client with a pneumothorax and a chest tube, which finding should the nurse notify the provider about?
- A. Movement of the trachea toward the unaffected side
- B. Bubbling of the water in the water seal chamber with exhalation
- C. Crepitus in the area above and surrounding the insertion site
- D. Eyelets not visible
Correct answer: A
Rationale: The movement of the trachea toward the unaffected side is concerning as it can indicate a tension pneumothorax, a life-threatening emergency that requires immediate intervention. The trachea should be midline, so any deviation should be reported promptly to the provider for further evaluation and intervention.
3. A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates an understanding of the teaching?
- A. "It might help if I tried sleeping only on my back."
- B. "I'll sleep better if I take a sleeping pill at night."
- C. "I'll get a humidifier to run at my bedside at night."
- D. "If I could lose about 50 pounds, I might stop having so many apneic episodes."
Correct answer: D
Rationale:
4. A client with chronic obstructive pulmonary disease (COPD tells the nurse, 'I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up.' Which of the following actions should the nurse take to help this client with tenacious bronchial secretions?
- A. Maintaining a semi-Fowler's position as often as possible
- B. Administering oxygen via nasal cannula at 2 L/min
- C. Helping the client select a low-salt diet
- D. Encouraging the client to drink 2 to 3 L of water daily
Correct answer: D
Rationale: Encouraging the client to drink 2 to 3 liters of water daily helps to thin bronchial secretions, making them easier to expectorate. This can assist the client in coughing up the tenacious secretions. Maintaining a semi-Fowler's position can aid in improving lung expansion but may not directly address the issue of clearing the secretions. Administering oxygen via nasal cannula at 2 L/min can help improve oxygenation but does not specifically target the removal of bronchial secretions. Selecting a low-salt diet is important for overall health, but it does not directly address the client's immediate concern of clearing the bronchial secretions.
5. While providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort, which of the following desired effects of medications should the nurse identify as most important for the client's recovery?
- A. It decreases the client's level of anxiety.
- B. It facilitates the client's deep breathing.
- C. It enhances the client's ability to sleep.
- D. It reduces the client's blood pressure.
Correct answer: B
Rationale: In the postoperative period following CABG surgery, deep breathing exercises are essential to prevent complications such as atelectasis and pneumonia. Opioid medications can depress the respiratory system, making it crucial for the nurse to emphasize the importance of deep breathing to maintain optimal lung function. While managing pain and anxiety are important, facilitating deep breathing takes precedence in this situation to promote effective recovery and prevent respiratory complications.
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