ATI RN
ATI Detailed Answer Key Medical Surgical
1. When admitting a client with active tuberculosis to a room on a medical-surgical unit, which of the following room assignments should the nurse make?
- A. A room with air exhaust directly to the outdoor environment
- B. A room with another nonsurgical client
- C. A room in the ICU
- D. A room that is within view of the nurses' station
Correct answer: A
Rationale: When admitting a client with active tuberculosis, it is crucial to assign them to a room with air exhaust directly to the outdoor environment to prevent the spread of infectious particles to other patients and healthcare workers. This setup helps in reducing the risk of transmission within the healthcare facility. Placing the client in a room with another nonsurgical client or in the ICU may increase the chances of spreading the infection. Additionally, placing the client in a room within view of the nurses' station does not address the need for proper ventilation to minimize transmission of tuberculosis.
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. While dining at a restaurant, a person begins to choke. Which of the following actions should the nurse take?
- A. Instruct the person to call 911.
- B. Ask the person if he/she can speak.
- C. Use the jaw-thrust maneuver.
- D. Perform abdominal thrusts.
Correct answer: B
Rationale: When encountering a choking individual, the nurse should first assess the person's ability to speak. If the person can speak, it indicates that their airway is partially obstructed, allowing some air to pass. In this case, encouraging the person to continue coughing and monitoring them closely may be appropriate. If the person cannot speak, it may suggest a complete airway obstruction and immediate intervention is required. Instructing the person to call 911 (Choice A) may be necessary if the situation worsens. Using the jaw-thrust maneuver (Choice C) is not appropriate for a choking victim. Performing abdominal thrusts (Choice D) is typically recommended for conscious choking victims, not chest compressions.
4. A client interested in smoking cessation is being taught by a nurse. Which statements should the nurse include in the teaching? (Select one that does not apply)
- A. Find an activity that you enjoy and will keep your hands busy.
- B. Keep snacks like potato chips on hand to nibble on.
- C. Drink at least eight glasses of water each day.
- D. Make a list of reasons for quitting smoking.
Correct answer: C
Rationale: When teaching a client interested in smoking cessation, the nurse should advise finding an activity that keeps the hands busy, keeping healthy snacks on hand, making a list of reasons for quitting smoking, and not being upset if a relapse occurs. Drinking eight glasses of water each day is a healthy habit but is not directly related to smoking cessation strategies, making it the option that does not apply in this context.
5. 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.
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