ATI RN
Medical Surgical ATI Proctored Exam
1. A client develops a pulmonary embolism. Which of the following interventions should the nurse implement first?
- A. Give morphine IV.
- B. Administer oxygen therapy.
- C. Start an IV infusion of lactated Ringer's.
- D. Initiate cardiac monitoring.
Correct answer: B
Rationale: Administering oxygen therapy is the priority intervention for a client with a pulmonary embolism. Oxygen helps improve oxygenation levels and decrease the workload on the heart. It is crucial to ensure adequate oxygenation before other interventions are initiated. Morphine IV, starting an IV infusion of lactated Ringer's, and initiating cardiac monitoring are important interventions but come after ensuring adequate oxygenation.
2. A healthcare professional is reviewing the arterial blood gas results for a client in the ICU who has kidney failure and determines the client has respiratory acidosis. Which of the following findings should the healthcare professional expect?
- A. Widened QRS complexes
- B. Hyperactive deep tendon reflexes
- C. Bounding peripheral pulses
- D. Warm, flushed skin
Correct answer: A
Rationale: Respiratory acidosis is a condition characterized by increased carbon dioxide levels in the blood, resulting in acidosis. One of the potential consequences of respiratory acidosis is the development of electrolyte imbalances, particularly hyperkalemia. Hyperkalemia can lead to cardiac conduction abnormalities, manifested as widened QRS complexes on an electrocardiogram (ECG). Therefore, in a client with respiratory acidosis, the healthcare professional should expect to find widened QRS complexes as a result of the associated hyperkalemia.
3. What should the nurse prioritize when monitoring an older adult client immediately following a bronchoscopy?
- A. Observing for confusion
- B. Auscultating breath sounds
- C. Confirming the gag reflex
- D. Measuring blood pressure
Correct answer: C
Rationale: Following a bronchoscopy, the priority for the nurse is to confirm the gag reflex in the older adult client. This is crucial to ensure that the client's airway is protected and free from any obstruction or aspiration. Monitoring the gag reflex helps in preventing complications such as aspiration pneumonia. While auscultating breath sounds, observing for confusion, and measuring blood pressure are important assessments, confirming the gag reflex takes precedence in this situation to maintain airway patency and prevent potential respiratory complications.
4. A client in the intensive care unit is receiving teaching before removal of an endotracheal tube. Which of the following instructions should the nurse include in the teaching?
- A. Rest in a side-lying position after the tube is removed.
- B. Use the incentive spirometer every 4 hours after the tube is removed.
- C. Avoid speaking for extended periods.
- D. Vital signs will be monitored by a nurse every 15 minutes in the first hour after the tube is removed.
Correct answer: C
Rationale: It is essential to advise the client to avoid speaking for extended periods after the removal of the endotracheal tube to prevent strain on the vocal cords and allow the airway to recover. Speaking for prolonged periods can lead to irritation and potentially affect the healing process. The other options are also important post-extubation instructions, such as using the incentive spirometer to maintain lung function, positioning in a side-lying position for comfort, and frequent monitoring of vital signs to ensure the client's stability.
5. During an admission assessment of a client with COPD and emphysema complaining of a frequent productive cough and shortness of breath, what assessment finding should the nurse anticipate?
- A. Respiratory alkalosis
- B. Increased anteroposterior diameter of the chest
- C. Oxygen saturation level 96%
- D. Petechiae on chest
Correct answer: B
Rationale: COPD and emphysema are chronic respiratory conditions that can lead to changes in the shape of the chest. In clients with COPD, the anteroposterior diameter of the chest often increases, giving a barrel chest appearance. This change in chest shape is due to hyperinflation of the lungs and is a common physical finding in clients with COPD and emphysema. The other options are not typically associated with COPD and emphysema. Respiratory alkalosis is not a common finding in these clients. An oxygen saturation level of 96% is within the normal range and does not specifically relate to COPD. Petechiae on the chest are not typically associated with COPD or emphysema.
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