ATI RN
ATI Detailed Answer Key Medical Surgical
1. A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?
- A. Insert an indwelling urinary catheter.
- B. Inspect the mouth for signs of inhalation injuries.
- C. Administer intravenous pain medication.
- D. Draw blood for a complete blood cell (CBC) count.
Correct answer: B
Rationale: When caring for a client with burns, especially burns to the face and chest, the priority action for the nurse is to inspect the mouth for signs of inhalation injuries. Inhalation injuries can be life-threatening and may not be immediately apparent. Identifying these injuries early allows for prompt intervention and can significantly impact the client's outcomes. While other actions such as pain management and blood tests are important, assessing for inhalation injuries takes precedence due to its critical nature.
2. A nurse is caring for a client post-myocardial infarction (MI). What is the priority assessment for this client?
- A. Monitoring urine output
- B. Checking blood glucose levels
- C. Assessing for chest pain
- D. Monitoring electrolyte levels
Correct answer: C
Rationale: Assessing for chest pain is crucial in post-MI clients as it can indicate complications such as reinfarction or ischemia.
3. A client with chronic obstructive pulmonary disease is receiving dietary teaching from a nurse. Which of the following instructions should the nurse include?
- A. Eat 3 balanced meals each day.
- B. Limit fluid intake with meals.
- C. Reduce sodium intake.
- D. Take a bronchodilator 1 hour before eating.
Correct answer: B
Rationale: In clients with chronic obstructive pulmonary disease, limiting fluid intake with meals can help reduce the risk of bloating and feeling too full, which can make breathing more difficult due to increased pressure on the diaphragm. It is important to encourage a balanced diet with appropriate fluid intake between meals to maintain hydration and proper nutrition. Options A, C, and D are not specifically related to dietary recommendations for clients with chronic obstructive pulmonary disease.
4. A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience should the nurse provide this service?
- A. African American churches
- B. Asian American groceries
- C. High school sports camps
- D. Women's health clinics
Correct answer: A
Rationale: The correct answer is African American churches. African Americans in the United States have one of the highest rates of hypertension globally. By providing services at African American churches, the nurse can effectively reach this priority population. While hypertension education and screening are essential for all groups, African Americans are the priority population for this intervention due to their disproportionately high rates of hypertension.
5. A client is postoperative following an intermaxillary fixation due to multiple facial fractures. Which type of equipment should be at the client's bedside?
- A. Wire cutters
- B. NG tube
- C. Urinary catheter tray
- D. IV infusion pump
Correct answer: A
Rationale: In a client who has undergone intermaxillary fixation for facial fractures, wire cutters are essential equipment to have at the bedside in case of emergencies such as airway compromise. These wire cutters allow prompt removal of the wires securing the jaw if needed to ensure adequate airway patency. NG tube, urinary catheter tray, and IV infusion pump are important pieces of equipment in various clinical scenarios but are not specifically required for managing intermaxillary fixation postoperatively.
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