ATI RN
ATI Medical Surgical Proctored Exam 2023
1. While assessing a client with a tracheostomy, a nurse notes that the tracheostomy tube is pulsing with the heartbeat during a pulse check. No other abnormal findings are noted. What action should the nurse take?
- A. Notify the operating room of a potential emergency case.
- B. No action is required at this time; this pulsation can be a normal finding in some clients.
- C. Remove the tracheostomy tube and ventilate the client using a bag-valve-mask.
- D. Stay with the client and ask someone else to contact the provider immediately.
Correct answer: D
Rationale: The pulsation of the tracheostomy tube with the heartbeat may indicate a tracheoinnominate artery fistula, which can lead to life-threatening hemorrhage if the artery is breached. In this scenario, as there is no active bleeding yet, the nurse should remain with the client and have another person notify the provider immediately. If the client starts to hemorrhage, the nurse should remove the tracheostomy tube and apply pressure at the bleeding site, preparing the client for urgent surgical intervention.
2. Which of the following is an example of a clinical decision support system (CDSS)?
- A. Electronic health record (EHR)
- B. Barcode medication administration
- C. Smart infusion pumps
- D. Automated drug dispensing system
Correct answer: C
Rationale: The correct answer is C, smart infusion pumps. Smart infusion pumps are an example of a clinical decision support system (CDSS) as they help ensure accurate medication delivery by providing alerts and dosage calculations. Choice A, electronic health record (EHR), is not a CDSS but rather a digital version of a patient's paper chart. Choice B, barcode medication administration, involves scanning barcodes to verify medication administration but is not a CDSS. Choice D, automated drug dispensing system, automates the medication dispensing process but is not specifically a CDSS.
3. A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP). Which of the following findings should the nurse report to the provider?
- A. Passing small clots in the urine.
- B. Continuous bladder irrigation.
- C. Red-tinged urine with numerous clots.
- D. Urine output of 50 mL/hr.
Correct answer: C
Rationale: The correct answer is C: Red-tinged urine with numerous clots. This finding should be reported because it indicates excessive bleeding following a TURP procedure. Passing small clots in the urine (choice A) is expected post-TURP. Continuous bladder irrigation (choice B) is a standard procedure after TURP to prevent clot retention. Urine output of 50 mL/hr (choice D) is within the expected range postoperatively and does not indicate a complication.
4. What best describes the primary goal of community health nursing?
- A. Promoting health and preventing disease
- B. Providing direct care to sick individuals
- C. Managing chronic conditions
- D. Evaluating health programs
Correct answer: A
Rationale: Community health nursing focuses on promoting health and preventing disease within the community. This approach emphasizes preventive care, health education, and community-based interventions to improve the overall health and well-being of individuals and populations. While providing care to sick individuals is part of nursing, the primary goal of community health nursing is broader and encompasses proactive strategies to enhance community health.
5. A client has returned from the surgical suite following surgery for a fractured mandible with intermaxillary fixation. Which of the following actions is the priority for the nurse to take?
- A. Prevent aspiration.
- B. Ensure adequate nutrition.
- C. Promote oral hygiene.
- D. Relieve the client's pain.
Correct answer: Prevent aspiration.
Rationale: Preventing aspiration is the priority for a client with intermaxillary fixation following mandibular surgery. Aspiration can occur due to difficulty swallowing or improper positioning, posing a serious risk to the client's respiratory status. It is crucial for the nurse to ensure that the client's airway is clear and that they are positioned correctly to prevent any potential aspiration events.
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