ATI RN
ATI Detailed Answer Key Medical Surgical
1. While caring for a client with extensive partial and full-thickness burns of the head, neck, and chest, which risk should the nurse prioritize for assessment and intervention?
- A. Airway obstruction
- B. Infection
- C. Fluid imbalance
- D. Paralytic ileus
Correct answer: A
Rationale: When a client sustains burns to the head, neck, or chest, the risk of airway obstruction is a critical concern due to potential swelling, inflammation, or inhalation injury. Any compromise to the airway can lead to severe respiratory distress or failure. Early recognition and intervention to maintain a clear airway are essential to prevent life-threatening complications in burn patients.
2. A healthcare professional is interested in making interdisciplinary work a high priority. Which actions by the professional best demonstrate this skill? (Select ONE that does not apply)
- A. Consulting with other disciplines on client care
- B. Coordinating discharge planning for home safety
- C. Participating in comprehensive client rounding
- D. Sharing the care plans with other disciplines
Correct answer: B
Rationale: Interdisciplinary work in healthcare involves effective communication and collaboration between different disciplines for holistic client care. Consulting with other disciplines allows for sharing expertise, insights, and perspectives to enhance client outcomes. Participating in comprehensive client rounding involves a team-based approach to discuss and plan client care collectively. Sharing nursing care plans with other disciplines ensures that all team members are informed and can contribute to the client's overall well-being. Coordinating discharge planning is important but may not directly demonstrate interdisciplinary collaboration as the other actions do.
3. During an assessment in the emergency department, an older adult client with community-acquired pneumonia is found to be confused. Which of the following findings should the nurse expect?
- A. Unequal pupils
- B. Hypertension
- C. Tympany upon chest percussion
- D. Confusion
Correct answer: D
Rationale: Confusion is a common finding in older adult clients with pneumonia, often indicating hypoxia. Hypertension, unequal pupils, and tympany upon chest percussion are not typically associated with community-acquired pneumonia in older adults.
4. A client is experiencing an acute exacerbation of asthma. Which medication should the nurse administer first?
- A. Albuterol (Proventil)
- B. Ipratropium (Atrovent)
- C. Salmeterol (Serevent)
- D. Fluticasone (Flovent)
Correct answer: A
Rationale: During an acute exacerbation of asthma, the priority is to administer a short-acting beta2-agonist like Albuterol (Proventil) first. Albuterol acts quickly to dilate the airways and provide immediate relief of bronchospasm. Ipratropium (Atrovent) is an anticholinergic that can be used as an adjunct therapy. Salmeterol (Serevent) is a long-acting beta2-agonist intended for maintenance therapy, not for acute exacerbations. Fluticasone (Flovent) is a corticosteroid used for long-term asthma control and should not be the initial medication given during an acute exacerbation.
5. When caring for a client with acute pancreatitis, what intervention is most appropriate?
- A. Encourage a high-protein diet.
- B. Administer pain medication as needed.
- C. Provide small, frequent meals.
- D. Increase oral fluid intake.
Correct answer: B
Rationale: Administering pain medication as needed is the most appropriate intervention for a client with acute pancreatitis. Pain management is crucial as pancreatitis can cause severe and debilitating pain. Providing pain relief is essential to improve the client's comfort and well-being.
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