ATI RN
ATI Detailed Answer Key Medical Surgical
1. A client in an emergency department has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?
- A. Raise the foot of the bed to a 90° angle
- B. Remove the dressing to inspect the wound
- C. Prepare to insert a central line
- D. Administer oxygen via nasal cannula
Correct answer: Administer oxygen via nasal cannula
Rationale: In a client with a sucking chest wound, the priority is to administer oxygen via nasal cannula to improve oxygenation. The client's blood pressure, weak pulse rate, and elevated respiratory rate indicate hypovolemic shock, so increasing oxygen supply is crucial. Raising the foot of the bed, removing the dressing, or preparing to insert a central line are not immediate actions needed for a client with a sucking chest wound and signs of shock.
2. A nurse is teaching a client about adding more fiber to his diet. The nurse should teach the client that which of the following foods has the highest fiber content?
- A. 1 cup cooked sweet potato
- B. 1 slice rye toast
- C. 1 cup raw watermelon
- D. 1 oz cashews
Correct answer: D
Rationale: Cashews have the highest fiber content among the options listed, which is important for improving digestive health.
3. A client is starting therapy with raloxifene. Which adverse effect should the client monitor for as instructed by the nurse?
- A. Leg cramps
- B. Hot flashes
- C. Urinary frequency
- D. Hair loss
Correct answer: B
Rationale: Hot flashes are a common adverse effect associated with raloxifene therapy. Raloxifene is a selective estrogen receptor modulator (SERM) used to prevent and treat osteoporosis in postmenopausal women. Hot flashes are a well-known side effect of SERMs due to their estrogen-like effects on the body. Leg cramps, urinary frequency, and hair loss are not typically associated with raloxifene therapy. Therefore, the nurse should instruct the client to monitor for hot flashes as part of the medication education.
4. Which of the following perspectives focuses on social determinants of behavior?
- A. The attachment perspective
- B. The interpersonal perspective
- C. The humanistic perspective
- D. The existential perspective
Correct answer: B
Rationale: The interpersonal perspective focuses on social determinants of behavior, emphasizing the impact of social interactions, relationships, and communication on an individual's behavior. This perspective looks at how people's behavior is influenced by their interactions with others and the social environment. Choices A, C, and D are incorrect because they do not primarily focus on social determinants of behavior. The attachment perspective is concerned with emotional bonds between individuals, the humanistic perspective emphasizes personal growth and self-fulfillment, and the existential perspective focuses on individual freedom and responsibility in creating meaning in life.
5. A client with heart failure is receiving discharge teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?
- A. I should weigh myself once a week.
- B. I should limit my fluid intake to 1 liter per day.
- C. I should report a weight gain of 2 pounds in one day.
- D. I should reduce my protein intake to prevent fluid retention.
Correct answer: C
Rationale: The correct answer is C. Reporting a sudden weight gain of 2 pounds in one day is crucial in managing heart failure because it can indicate fluid retention, a common symptom in heart failure. Option A is incorrect as weighing oneself once a week may not provide timely information about fluid retention. Option B is incorrect because fluid intake restriction is individualized and generally involves more specific guidance. Option D is incorrect as protein intake is important but reducing it solely to avoid fluid retention is not the primary focus in heart failure management.
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