ATI RN
ATI Medical Surgical Proctored Exam 2023
1. A nursing student is providing tracheostomy care. What action by the student requires intervention by the instructor?
- A. Holding the device securely when changing ties
- B. Suctioning the client first if secretions are present
- C. Tying a square knot at the back of the neck
- D. Using half-strength peroxide for cleansing
Correct answer: C
Rationale: When providing tracheostomy care, it is important to ensure the client's safety and prevent pressure ulcers. When securing ties that require knotting, the knot should be placed at the side of the client's neck, not at the back. Tying a square knot at the back of the neck could lead to discomfort, pressure ulcers, or accidental tightening. Holding the device securely, suctioning the client as needed, and using appropriate cleansing solutions are all essential components of tracheostomy care.
2. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP) for a client receiving O2 at 4 liters per nasal cannula?
- A. Apply water-soluble ointment to nares and lips.
- B. Periodically adjust the oxygen flow rate.
- C. Remove the tubing from the client's nose.
- D. Turn the client every 2 hours or as needed.
Correct answer: A
Rationale: When a client is receiving oxygen at a high flow rate, it can cause drying of the nasal passages and lips. Therefore, a comfort measure that can be delegated to unlicensed assistive personnel (UAP) is applying water-soluble ointment to the client's nares and lips. Adjusting the oxygen flow rate should be done by licensed nursing staff, not UAP. Removing the tubing can disrupt the oxygen delivery and should be performed by trained personnel. Turning the client every 2 hours is a general comfort measure but is not specific to addressing the drying effects of oxygen therapy.
3. A healthcare professional is caring for four clients on intravenous heparin therapy. Which lab value possibly indicates a serious side effect has occurred?
- A. Hemoglobin: 14.2 g/dL
- B. Platelet count: 82,000/µL
- C. RBC count: 4.8 x 10^6/µL
- D. WBC count: 8.7 x 10^3/µL
Correct answer: B
Rationale: A low platelet count, as seen in choice B, is concerning as it could indicate heparin-induced thrombocytopenia, a serious side effect of heparin therapy. Heparin-induced thrombocytopenia can lead to an increased risk of blood clotting, potentially causing severe complications. Monitoring platelet counts is crucial during heparin therapy to promptly identify and manage this adverse effect.
4. After a thoracentesis, a healthcare provider assesses a client. Which assessment finding warrants immediate action?
- A. The client rates pain as 5/10 at the site of the procedure.
- B. A small amount of drainage is noted from the site.
- C. Pulse oximetry reads 93% on 2 liters of oxygen.
- D. The trachea is deviated toward the opposite side of the neck.
Correct answer: D
Rationale: A deviated trachea indicates a tension pneumothorax, a life-threatening emergency. This condition can rapidly lead to respiratory failure and requires immediate intervention. The other assessment findings, such as pain level, mild drainage, and slightly decreased oxygen saturation, are within an expected range after a thoracentesis and do not indicate an immediate threat to the client's life.
5. A client with chronic obstructive pulmonary disease (COPD) is being assessed by a nurse. Which finding does the nurse expect?
- A. Increased anteroposterior (AP) chest diameter
- B. Decreased respiratory rate
- C. Weight gain
- D. Productive cough with yellow sputum
Correct answer: A
Rationale: Clients with COPD commonly develop a barrel chest, characterized by an increased anteroposterior diameter of the chest. This change is due to chronic air trapping and hyperinflation of the lungs. A decreased respiratory rate, weight gain, and productive cough with yellow sputum are not typical findings in COPD. Instead, COPD patients often present with an increased respiratory rate, weight loss, and a chronic cough with sputum production.
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