ATI RN
ATI Detailed Answer Key Medical Surgical
1. A client in an emergency department has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?
- A. Raise the foot of the bed to a 90° angle
- B. Remove the dressing to inspect the wound
- C. Prepare to insert a central line
- D. Administer oxygen via nasal cannula
Correct answer: D
Rationale: In a client with a sucking chest wound, the priority is to administer oxygen via nasal cannula to improve oxygenation. The client's blood pressure, weak pulse rate, and elevated respiratory rate indicate hypovolemic shock, so increasing oxygen supply is crucial. Raising the foot of the bed, removing the dressing, or preparing to insert a central line are not immediate actions needed for a client with a sucking chest wound and signs of shock.
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 client underwent a total laryngectomy. Which of the following is the priority observation in the client's care?
- A. Patency of the intravenous line
- B. Level of pain
- C. Integrity of the dressing
- D. Need for suctioning
Correct answer: D
Rationale: Following a total laryngectomy, maintaining a clear airway is crucial to prevent complications such as airway obstruction due to secretions or blood clots. Monitoring the need for suctioning takes precedence to ensure the client's airway remains patent. While monitoring pain levels, IV line patency, and dressing integrity are important aspects of care, ensuring adequate airway clearance through suctioning is the priority in this scenario.
4. A client with emphysema is being cared for by a nurse. Which of the following findings should the nurse not expect to assess in this client?
- A. Dyspnea
- B. Bradycardia
- C. Barrel chest
- D. Clubbing of the fingers
Correct answer: B
Rationale: Emphysema is a chronic lung condition characterized by shortness of breath (dyspnea), a barrel-shaped chest due to hyperinflation of the lungs (barrel chest), and clubbing of the fingers (enlargement of fingertips). Bradycardia (slow heart rate) is not typically associated with emphysema. In emphysema, the primary focus is on respiratory complications rather than cardiac issues.
5. A client has returned from the surgical suite following surgery for a fractured mandible with intermaxillary fixation. Which of the following actions is the priority for the nurse to take?
- A. Prevent aspiration.
- B. Ensure adequate nutrition.
- C. Promote oral hygiene.
- D. Relieve the client's pain.
Correct answer: A
Rationale: Preventing aspiration is the priority for a client with intermaxillary fixation following mandibular surgery. Aspiration can occur due to difficulty swallowing or improper positioning, posing a serious risk to the client's respiratory status. It is crucial for the nurse to ensure that the client's airway is clear and that they are positioned correctly to prevent any potential aspiration events.
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