ATI RN
ATI RN Adult Medical Surgical Online Practice 2023 A
1. A client had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first?
- A. Observe for cerebrospinal fluid (CSF) leaks from the evacuation site.
- B. Assess for an increase in temperature.
- C. Check the oximeter.
- D. Monitor for manifestations of increased intracranial pressure.
Correct answer: C
Rationale: When caring for a client who had an evacuation of a subdural hematoma, the nurse's priority is to check the oximeter. Monitoring oxygen saturation is crucial to ensure adequate tissue oxygenation, especially after such a procedure. This assessment helps in early detection of hypoxemia, which can be detrimental to the client's recovery. While observing for CSF leaks, assessing for temperature changes, and monitoring for signs of increased intracranial pressure are important, checking the oximeter takes precedence to address immediate oxygenation needs.
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: A
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. Prior to performing percussion, vibration, and postural drainage on an adolescent client with pneumonia, which of the following nursing actions should the nurse complete first?
- A. Auscultate lung fields
- B. Assess pulse and respirations
- C. Assess characteristics of the sputum
- D. Instruct the client to slowly exhale with pursed lips
Correct answer: A
Rationale: Before initiating percussion, vibration, and postural drainage, the nurse should first auscultate the lung fields to assess the baseline lung sounds and identify areas of congestion or abnormality. This initial assessment helps the nurse to tailor the percussion and drainage techniques effectively. Assessing pulse and respirations, sputum characteristics, and providing instructions to the client for exhalation are important steps in the procedure but should follow the initial auscultation to ensure a comprehensive and individualized care approach.
4. A healthcare provider suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following should be the healthcare provider's priority intervention?
- A. Insert an IV line
- B. Count the respiratory rate
- C. Administer oxygen
- D. Prepare equipment for intubation
Correct answer: B
Rationale: When suspecting anaphylaxis, the priority intervention is to assess the client's respiratory status by counting the respiratory rate. Respiratory distress is a hallmark sign of anaphylaxis, and prompt recognition and management are crucial. Administering oxygen may be necessary, but assessing the respiratory rate takes precedence to determine the severity of the reaction and the need for immediate intervention. Inserting an IV line and preparing for intubation are important interventions in managing anaphylaxis but are secondary to ensuring adequate ventilation.
5. A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first?
- A. Urticaria
- B. Stridor
- C. Vomiting
- D. Hypotension
Correct answer: B
Rationale:
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