ATI RN
ATI RN Adult Medical Surgical Online Practice 2023 A
1. A nurse is caring for a client who is postoperative following surgical repair of a mandibular fracture with fixed occlusion of the jaws in a closed position. Which of the following statements is the priority for the nurse to make?
- A. "We can teach you some relaxation techniques to minimize your pain."
- B. "Keep wire cutters with you at all times."
- C. "Use a water pick device to keep your teeth clean."
- D. "Consume a high-protein, liquid diet."
Correct answer: "Keep wire cutters with you at all times."
Rationale:
2. A client just had a flexible bronchoscopy. Which of the following nursing actions is appropriate?
- A. Withhold food and liquids until the client’s gag reflex returns.
- B. Irrigate the client’s throat every 4 hours.
- C. Have the client refrain from talking for 24 hours.
- D. Suction the client’s oropharynx frequently.
Correct answer: Withhold food and liquids until the client’s gag reflex returns.
Rationale: After a flexible bronchoscopy, it is crucial to withhold food and liquids until the client's gag reflex returns to prevent aspiration. Irrigating the client's throat every 4 hours, having the client refrain from talking for 24 hours, and frequent suctioning of the oropharynx are not indicated post-bronchoscopy and may even pose risks to the client's recovery.
3. A nurse in the PACU is assessing a client who has an endotracheal tube (ET) in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?
- A. Blockage of the ET tube by the client's tongue
- B. Passage of the ET tube into the esophagus
- C. Movement of the ET tube into the right main bronchus
- D. Infection of the vocal cords
Correct answer: C: Movement of the ET tube into the right main bronchus
Rationale: When the nurse observes the absence of left-sided chest wall expansion upon respiration, it indicates that the endotracheal tube (ET) may have migrated into the right main bronchus, leading to uneven chest expansion. This can result in inadequate ventilation to the left lung, causing respiratory compromise. The other options, such as blockage of the ET tube by the client's tongue, passage of the ET tube into the esophagus, and infection of the vocal cords, do not directly explain the observed chest wall asymmetry and respiratory distress.
4. A client has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should be taken?
- A. Increase the wall suction.
- B. Strip the chest tube.
- C. Clamp the chest tube.
- D. Reposition the client.
Correct answer: Reposition the client.
Rationale: When a client with a chest tube connected to wall suction complains of chest burning, it may indicate that the tube is irritating or compressing nearby tissues. Repositioning the client can help relieve this irritation by ensuring the tube is not kinked or pulling on the tissues. Increasing suction, stripping the tube, or clamping it are not appropriate actions and could potentially worsen the situation or cause harm.
5. The trauma unit nurse has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?
- A. Evaluate chest expansion.
- B. Check pupillary response to light.
- C. Assess the capillary refill.
- D. Check the client’s response to questions about place and time.
Correct answer: A: Evaluate chest expansion.
Rationale: In a client with multiple injuries following a motor vehicle crash, the priority is to assess for any compromised airway or breathing. Evaluating chest expansion helps the nurse determine if the client is having any difficulty breathing, which is essential for immediate intervention to maintain adequate oxygenation. Checking pupillary response, assessing capillary refill, and checking the client’s orientation to place and time are important assessments but are of lower priority compared to ensuring the client's airway and breathing are intact.
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