ATI RN
ATI Medical Surgical Proctored Exam 2023
1. A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the client's face is puffy, and the eyelids are swollen. What action by the nurse takes priority?
- A. Assess the client's oxygen saturation.
- B. Notify the Rapid Response Team.
- C. Oxygenate the client with a bag-valve-mask.
- D. Palpate the skin of the upper chest.
Correct answer: A
Rationale: In this scenario, the client may have subcutaneous emphysema, where air leaks into the tissues surrounding the tracheostomy. The priority action for the nurse is to assess the client's oxygen saturation and other indicators of oxygenation to ensure adequate oxygen supply. If the client is stable, the nurse can then proceed to palpate the skin of the upper chest to check for subcutaneous emphysema. If the client is unstable, the nurse should promptly notify the Rapid Response Team. Using a bag-valve-mask device may be necessary for oxygenating the client, but assessing oxygen saturation comes first to guide further interventions.
2. 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.
3. A client with a mediastinal chest tube is being assessed by a nurse. Which symptoms require the nurse's immediate intervention? (SATA)
- A. Production of pink sputum
- B. Tracheal deviation
- C. Pain at insertion site
- D. Sudden onset of shortness of breath
Correct answer: B
Rationale: Immediate intervention is necessary when a client with a mediastinal chest tube exhibits tracheal deviation since it may indicate a tension pneumothorax. This condition requires prompt attention to prevent serious complications. While the production of pink sputum and pain at the insertion site should be monitored and reported, they do not typically require immediate intervention. Sudden onset of shortness of breath could indicate various issues related to the chest tube but is not as critical as tracheal deviation in this context.
4. During an acute asthma attack, a healthcare provider assesses a client. Which assessment finding indicates that the client's condition is worsening?
- A. Loud wheezing
- B. Increased respiratory rate
- C. Decreased breath sounds
- D. Productive cough
Correct answer: C
Rationale: In a client experiencing an acute asthma attack, decreased breath sounds suggest severe airway obstruction or respiratory fatigue, indicating a worsening condition. Loud wheezing, increased respiratory rate, and a productive cough are common manifestations during an asthma attack as the airways constrict, leading to turbulent airflow causing wheezing, increased effort to breathe resulting in a higher respiratory rate, and mucus production causing a productive cough. However, decreased breath sounds signify a critical situation requiring immediate intervention.
5. A client is receiving oxygen therapy via nasal cannula. Which finding indicates that the therapy is effective?
- A. The client is able to ambulate in the hall without dyspnea.
- B. The client has a respiratory rate of 24 breaths per minute.
- C. The client's oxygen saturation is 92%.
- D. The client has a productive cough.
Correct answer: A
Rationale: The correct answer is A. Effective oxygen therapy should improve the client's ability to perform activities without dyspnea. This indicates that the oxygen therapy is adequately supporting the client's respiratory needs. An oxygen saturation of 92% may suggest the need for a higher flow rate to improve oxygenation. A respiratory rate of 24 breaths per minute is elevated, indicating potential respiratory distress. A productive cough does not necessarily indicate effective oxygen therapy, as it is a symptom of respiratory irritation or infection, not oxygenation status.
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