ATI RN
ATI Detailed Answer Key Medical Surgical
1. When assessing a client with a pneumothorax and a chest tube, which finding should the nurse notify the provider about?
- A. Movement of the trachea toward the unaffected side
- B. Bubbling of the water in the water seal chamber with exhalation
- C. Crepitus in the area above and surrounding the insertion site
- D. Eyelets not visible
Correct answer: A: Movement of the trachea toward the unaffected side
Rationale: The movement of the trachea toward the unaffected side is concerning as it can indicate a tension pneumothorax, a life-threatening emergency that requires immediate intervention. The trachea should be midline, so any deviation should be reported promptly to the provider for further evaluation and intervention.
2. The client is complaining of painful swallowing secondary to mouth ulcers. Which statement by the client indicates appropriate management?
- A. “I will brush my teeth with a soft-bristle toothbrush.”
- B. “I will rinse my mouth with Listerine mouthwash.”
- C. “I will swish my antifungal solution and then swallow.”
- D. “I will avoid spicy foods, tobacco, and alcohol.”
Correct answer: D
Rationale: The correct answer is D. Avoiding irritants like spicy foods, tobacco, and alcohol is crucial in managing mouth ulcers as they can further irritate and worsen the condition. Choice A is incorrect as using a soft-bristle toothbrush may still cause discomfort. Choice B is incorrect as alcohol-containing mouthwashes can be irritating. Choice C is incorrect as swallowing antifungal solution meant for topical use is not appropriate and can be harmful.
3. During an assessment, which manifestation should a healthcare provider expect in an infant with pyloric stenosis?
- A. Bile-stained vomitus
- B. Distended abdomen
- C. Olive-shaped mass in the upper abdomen
- D. Painless, swollen joints
Correct answer: C
Rationale: Pyloric stenosis in infants typically presents with an olive-shaped mass in the upper abdomen due to hypertrophy of the pyloric muscle. This mass can often be palpated during an assessment and is a key characteristic of this condition. Bile-stained vomitus may be seen in conditions such as intestinal obstruction; a distended abdomen can be a nonspecific sign of various conditions, and painless, swollen joints are not typically associated with pyloric stenosis.
4. Kevin has a history of peptic ulcer disease and vomits coffee-ground emesis. What does this indicate?
- A. He has fresh, active upper GI bleeding.
- B. He needs immediate saline gastric lavage.
- C. His gastric bleeding occurred 2 hours earlier.
- D. He needs a transfusion of packed RBC’s.
Correct answer: C
Rationale: Coffee-ground emesis indicates that the gastric bleeding occurred 2 hours earlier.
5. During adolescence, the young person's vision of self becomes __________.
- A. more inconsistent
- B. more well-organized
- C. less complex
- D. unbalanced
Correct answer: B
Rationale: During adolescence, self-concept becomes more organized and consistent as individuals integrate different aspects of their identity. This process involves understanding oneself better, recognizing strengths and weaknesses, and forming a more coherent sense of identity. Choices A, C, and D are incorrect because adolescence is typically a period of increased self-awareness and growth, leading to a more structured and integrated self-concept, rather than one that is inconsistent, less complex, or unbalanced.
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