ATI RN
ATI Detailed Answer Key Medical Surgical
1. A client with a chest tube connected to a closed drainage system needs to be transported to the x-ray department. Which of the following actions should the nurse take?
- A. Clamp the chest tube prior to transferring the client to a wheelchair.
- B. Disconnect the chest tube from the drainage system during transport.
- C. Keep the drainage system below the level of the client's chest at all times.
- D. Empty the collection chamber prior to transport.
Correct answer: C
Rationale: When transporting a client with a chest tube connected to a closed drainage system, it is crucial to keep the drainage system below the level of the client's chest at all times. This positioning prevents the backflow of drainage into the client's chest, reducing the risk of complications. Clamping the chest tube, disconnecting it from the drainage system, or emptying the collection chamber are incorrect actions and can potentially harm the client or lead to complications.
2. 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.
3. A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?
- A. Insert an indwelling urinary catheter.
- B. Inspect the mouth for signs of inhalation injuries.
- C. Administer intravenous pain medication.
- D. Draw blood for a complete blood cell (CBC) count.
Correct answer: B
Rationale: When caring for a client with burns, especially burns to the face and chest, the priority action for the nurse is to inspect the mouth for signs of inhalation injuries. Inhalation injuries can be life-threatening and may not be immediately apparent. Identifying these injuries early allows for prompt intervention and can significantly impact the client's outcomes. While other actions such as pain management and blood tests are important, assessing for inhalation injuries takes precedence due to its critical nature.
4. A post-anesthesia care unit nurse is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give the highest priority to?
- A. Arterial blood gases
- B. Urinary output
- C. Chest tube drainage
- D. Pain level
Correct answer: A
Rationale: Arterial blood gases are crucial to assess postoperatively in a client who has undergone thoracotomy and lobectomy to monitor oxygenation and ventilation status. Changes in arterial blood gases can indicate respiratory complications or inadequate gas exchange, which are critical issues that need prompt intervention to prevent further complications. While urinary output, chest tube drainage, and pain level are important assessments, monitoring arterial blood gases takes precedence in this specific postoperative scenario to ensure optimal respiratory function and overall patient well-being.
5. A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?
- A. The client who has been NPO since midnight for endoscopy
- B. The client who has left-sided heart failure and has a brain natriuretic peptide (BNP) level of 600 pg/mL
- C. The client who has end-stage renal failure and is scheduled for dialysis today
- D. The client who has gastroenteritis and is febrile
Correct answer: D
Rationale: Gastroenteritis can lead to fluid loss through vomiting and diarrhea, especially when accompanied by fever. Fever can increase insensible water loss through sweating as well. Both vomiting and diarrhea can significantly contribute to fluid volume deficit, making the client with gastroenteritis and fever at higher risk compared to the other clients described in the options.
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