ATI RN
ATI Detailed Answer Key Medical Surgical
1. A healthcare worker is caring for a group of clients in an infectious disease unit. The worker should wear an OSHA-approved N95 respirator mask when caring for a client with which of the following infectious diseases?
- A. Pertussis
- B. Mycoplasma pneumonia
- C. Tuberculosis
- D. Respiratory syncytial virus
Correct answer: C
Rationale: An OSHA-approved N95 respirator mask is recommended when caring for a client with tuberculosis due to the airborne transmission of the disease. Tuberculosis poses a higher risk of transmission via respiratory droplets, making respiratory protection essential to prevent exposure and infection among healthcare workers.
2. A client developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect?
- A. Decreased serum calcium level
- B. Decreased level of serum lipids
- C. Decreased erythrocyte sedimentation rate (ESR)
- D. Increased platelet count
Correct answer: A
Rationale: In fat embolism syndrome (FES), fat globules enter the bloodstream and can lead to various complications, including a decrease in serum calcium levels. This occurs due to the formation of fat emboli in the vessels, which can interfere with calcium metabolism. Therefore, a decreased serum calcium level is an expected laboratory finding in a client with fat embolism syndrome.
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 healthcare professional is assessing a client who has a fracture of the femur. Vital signs are obtained on admission and again in 2 hours. Which of the following changes in assessment should indicate to the healthcare professional that the client could be developing a serious complication?
- A. Increased respiratory rate from 18 to 44/min
- B. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F)
- C. Increased blood pressure from 112/68 to 120/72 mm Hg
- D. Increased heart rate from 68 to 72/min
Correct answer: A
Rationale: An increased respiratory rate from 18 to 44/min is a significant change that should alert the healthcare professional to a potential serious complication. Such a drastic increase in respiratory rate may indicate respiratory distress or hypoxia, which are critical conditions requiring immediate attention. The other options show minor changes in vital signs that are within normal limits and are less likely to indicate a serious complication.
5. A client is unconscious with a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?
- A. Kussmaul respirations
- B. Apneustic respirations
- C. Cheyne-Stokes respirations
- D. Stridor
Correct answer: C
Rationale: Cheyne-Stokes respirations are characterized by periods of deep, rapid breathing followed by periods of apnea. This pattern is often seen in clients with neurological or cardiac conditions. Kussmaul respirations are deep and rapid breaths often associated with metabolic acidosis. Apneustic respirations are characterized by prolonged inhalations with shortened exhalations and can indicate damage to the pons. Stridor is a high-pitched, noisy respiratory sound usually associated with upper airway obstruction. Therefore, in this scenario, the client's alternating pattern of hyperventilation and apnea aligns with Cheyne-Stokes respirations.
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