ATI RN
ATI Detailed Answer Key Medical Surgical
1. A post-anesthesia care unit nurse is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give the highest priority to?
- A. Arterial blood gases
- B. Urinary output
- C. Chest tube drainage
- D. Pain level
Correct answer: A
Rationale: Arterial blood gases are crucial to assess postoperatively in a client who has undergone thoracotomy and lobectomy to monitor oxygenation and ventilation status. Changes in arterial blood gases can indicate respiratory complications or inadequate gas exchange, which are critical issues that need prompt intervention to prevent further complications. While urinary output, chest tube drainage, and pain level are important assessments, monitoring arterial blood gases takes precedence in this specific postoperative scenario to ensure optimal respiratory function and overall patient well-being.
2. A nurse cares for a client with chronic obstructive pulmonary disease who has been prescribed continuous oxygen therapy at home. Which statement indicates the client correctly understands the teaching?
- A. I plan to wear my oxygen when I exercise & feel short of breath.
- B. I will use my portable oxygen when grilling burgers in the backyard.
- C. I plan to use cotton balls to cushion the oxygen tubing on my ears.
- D. I will only smoke while I am wearing my oxygen via nasal cannula.
Correct answer: C
Rationale: Cotton balls can decrease pressure ulcers from the oxygen tubing. Continuous oxygen orders mean the client should wear the oxygen at all times. Oxygen fuels a fire. Wearing oxygen while grilling & smoking increases the risk for fire.
3. During an asthma attack, a healthcare provider is assessing a client for hypoxemia. Which of the following manifestations should the provider expect?
- A. Nausea
- B. Dysphagia
- C. Agitation
- D. Hypotension
Correct answer: C
Rationale: During an asthma attack, hypoxemia can lead to inadequate oxygen supply to the brain, causing symptoms like restlessness, confusion, and agitation. These manifestations result from the body's response to low oxygen levels, aiming to increase oxygenation. Nausea, dysphagia, and hypotension are not typical manifestations of hypoxemia during an asthma attack.
4. During an assessment, a client with a long history of smoking and suspected laryngeal cancer will most likely report which early manifestation?
- A. Dysphagia
- B. Hoarseness
- C. Dyspnea
- D. Weight loss
Correct answer: B
Rationale: In clients with laryngeal cancer, hoarseness is often one of the earliest manifestations due to vocal cord involvement. The irritation and inflammation caused by the tumor affect the vocal cords, leading to changes in voice quality. Dysphagia (choice A) typically occurs later as the tumor grows and interferes with swallowing. Dyspnea (choice C) and weight loss (choice D) may occur as the cancer progresses, but hoarseness is usually among the first signs to manifest in laryngeal cancer.
5. A nurse cares for a female client who has a family history of cystic fibrosis. The client asks, Will my children have cystic fibrosis? How should the nurse respond?
- A. Since many of your family members are carriers, your children will also be carriers of the gene.
- B. Cystic fibrosis is an autosomal recessive disorder. If you are a carrier, your children will have the disorder.
- C. Since you have a family history of cystic fibrosis, I would encourage you & your partner to be tested.
- D. Cystic fibrosis is caused by a protein that controls the movement of chloride. Adjusting your diet will decrease the spread of this disorder.
Correct answer: C
Rationale: Cystic fibrosis is an autosomal recessive disorder in which both gene alleles must be mutated for the disorder to be expressed. The nurse should encourage both the client & partner to be tested for the abnormal gene. The other statements are not true.
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