a nurse is assessing a client who has a fracture of the femur the nurse obtains vital signs on admission and again in 2 hours which of the following c
Logo

Nursing Elites

ATI RN

ATI Detailed Answer Key Medical Surgical

1. A healthcare professional is assessing a client who has a fracture of the femur. Vital signs are obtained on admission and again in 2 hours. Which of the following changes in assessment should indicate to the healthcare professional that the client could be developing a serious complication?

Correct answer: A

Rationale: An increased respiratory rate from 18 to 44/min is a significant change that should alert the healthcare professional to a potential serious complication. Such a drastic increase in respiratory rate may indicate respiratory distress or hypoxia, which are critical conditions requiring immediate attention. The other options show minor changes in vital signs that are within normal limits and are less likely to indicate a serious complication.

2. A healthcare professional is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the healthcare professional expect?

Correct answer: D

Rationale: Postoperative atelectasis can lead to hypoxia, which causes respiratory distress. Intercostal retractions, where the muscles between the ribs pull inward during inspiration, are a common sign of respiratory distress in a client with atelectasis. Bradycardia (slow heart rate), Bradypnea (slow breathing rate), and lethargy are not typically associated with atelectasis and hypoxia.

3. A client was exposed to anthrax. Which of the following antibiotics should the nurse plan to administer?

Correct answer: A

Rationale: In the case of anthrax exposure, the recommended antibiotic for prophylaxis and treatment is Ciprofloxacin. Ciprofloxacin is effective against the anthrax bacterium, Bacillus anthracis. Fluconazole is an antifungal medication, Tobramycin is an aminoglycoside antibiotic used for bacterial infections, and Vancomycin is a glycopeptide antibiotic primarily used for Gram-positive bacterial infections. Therefore, the correct choice is Ciprofloxacin.

4. The healthcare provider is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the healthcare provider that the chest tube is functioning properly?

Correct answer: A

Rationale: Fluctuation of the fluid level within the water seal chamber indicates proper functioning of the chest tube. This fluctuation reflects the normal ebb and flow of air and fluid in the pleural space, demonstrating that the system is maintaining the appropriate pressure. Continuous bubbling in the water seal chamber may indicate an air leak, absence of fluid in the drainage tubing suggests a blockage, and equal amounts of fluid drainage in each collection chamber are not expected in this system.

5. A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best?

Correct answer: B

Rationale: Most people with hypertension are asymptomatic, although a small percentage do have symptoms such as headache. The nurse should explain this to the client. Asking about paying for medications is not related because the client has already admitted nonadherence. Threatening the client with possible complications will not increase compliance.

Similar Questions

When a client develops an airway obstruction from a foreign body but remains conscious, which of the following actions should the nurse take first?
How does the pain of a myocardial infarction (MI) differ from stable angina?
How can a nurse manager best improve hand-off communication among the staff? (SATA)
A nurse teaches a client with tuberculosis (TB) who is being discharged. Which statement by the client indicates a need for further teaching?
A client with a mediastinal chest tube is being assessed by a nurse. Which symptoms require the nurse's immediate intervention? (SATA)

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses