ATI RN
ATI Medical Surgical Proctored Exam
1. A client is receiving discharge teaching after a total hip replacement. Which statement by the client indicates a need for further teaching?
- A. I will avoid crossing my legs when sitting.
- B. I can sleep on my side as long as I use a pillow between my legs.
- C. I will avoid bending at the waist to pick things up.
- D. I can bend down to tie my shoes after 2 weeks.
Correct answer: D
Rationale: After a total hip replacement, clients should avoid bending at the waist past 90 degrees for at least 6 weeks to prevent dislocation of the hip prosthesis. Bending down to tie shoes involves significant hip flexion and should be avoided during the initial postoperative period to ensure proper healing and reduce the risk of complications.
2. When caring for an older adult client with a pulmonary infection, what action should the nurse take first?
- A. Encourage the client to increase fluid intake.
- B. Assess the client's level of consciousness.
- C. Raise the head of the bed to at least 45 degrees.
- D. Provide the client with humidified oxygen.
Correct answer: B
Rationale: Assessing the client's level of consciousness is the priority because it provides crucial information on the client's neurological status and response to the infection. Changes in consciousness can indicate deterioration or improvement in the client's condition, guiding further interventions and treatment.
3. A client who is intubated and has an intra-aortic balloon pump is restless and agitated. What action should the nurse perform first for comfort?
- A. Allow family members to remain at the bedside.
- B. Ask the family if the client would like a fan in the room.
- C. Keep the television tuned to the client's favorite channel.
- D. Speak loudly to the client in case of hearing problems.
Correct answer: A
Rationale: Allowing the family to remain at the bedside can help calm the client with familiar voices and presence, potentially reducing restlessness and agitation. Introducing a fan may not be the priority as it can spread germs through air movement. Keeping the television on all the time may not promote rest and recovery. Speaking loudly is not advisable as it may further agitate the client. Therefore, the initial action of allowing family members to stay is most likely to provide comfort and reassurance to the client.
4. A nurse is assessing a client with a history of seizures. Which assessment finding requires immediate intervention?
- A. The client is experiencing an aura.
- B. The client's antiseizure medication level is within the therapeutic range.
- C. The client has been seizure-free for 2 years.
- D. The client's seizure activity lasts longer than 5 minutes.
Correct answer: D
Rationale: Seizure activity lasting longer than 5 minutes requires immediate intervention as it can lead to status epilepticus, a medical emergency.
5. When orienting a new client and family to the inpatient unit, what information should the nurse provide to help the client promote their own safety?
- A. Encourage the client and family to be active partners.
- B. Instruct the client to monitor hand hygiene in caregivers.
- C. Offer the family the opportunity to stay with the client.
- D. Advise the client to always wear their armband.
Correct answer: A
Rationale: Encouraging the client and family to be active partners in their healthcare is crucial for promoting safety. When clients and families actively participate, they are more likely to advocate for themselves, ask questions, and be engaged in their care, leading to better outcomes and reduced risks.
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