ATI RN
ATI Detailed Answer Key Medical Surgical
1. A client is 12 hours postoperative and has a chest tube to a disposable water-seal drainage system with suction. The healthcare provider should intervene for which of the following observations?
- A. Constant bubbling in the suction-control chamber
- B. Continuous bubbling in the water-seal chamber
- C. Bloody drainage in the collection chamber
- D. Fluid-level fluctuations in the water-seal chamber
Correct answer: B
Rationale: Continuous bubbling in the water-seal chamber indicates an air leak, which can compromise the system's integrity and affect the client's respiratory status. The other options are expected findings in a client with a chest tube drainage system: constant bubbling in the suction-control chamber indicates proper suction function, bloody drainage in the collection chamber is expected in the immediate postoperative period, and fluid-level fluctuations in the water-seal chamber demonstrate normal drainage and lung re-expansion.
2. When working as a professional nurse, what is the priority for a new nurse working on an inpatient medical-surgical unit with a preceptor?
- A. Attending to holistic client needs
- B. Ensuring client safety
- C. Avoiding medication errors
- D. Providing client-focused care
Correct answer: B
Rationale: The priority for a nurse working on an inpatient medical-surgical unit is to ensure client safety. This is crucial as errors in hospital care can lead to preventable deaths. While attending to holistic client needs and providing client-focused care are important aspects of nursing, ensuring client safety takes precedence to prevent harm and promote positive patient outcomes.
3. A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take?
- A. Perform suctioning for up to four passes.
- B. Apply suction to the catheter when advancing it into the trachea.
- C. Preoxygenate the client with 100% oxygen for up to 3 min.
- D. Limit each suction pass to 25 seconds.
Correct answer: C
Rationale:
4. The client is prescribed a long-acting beta2 agonist and expresses concerns about the cost, stating they only use the inhaler during asthma attacks. How should the nurse respond?
- A. Explain the importance of using the inhaler daily to prevent asthma attacks.
- B. Suggest identifying community services to help with the cost and encourage daily use of the inhaler.
- C. Explore the client's fears regarding breathlessness.
- D. Emphasize the necessity of using this inhaler daily and discuss potential community services for financial assistance.
Correct answer: B
Rationale: The correct response should address the client's concern about the cost of using the inhaler daily. While emphasizing the importance of daily use is crucial, it is also essential to acknowledge and offer support for the financial burden. Identifying community resources can help the client access affordable medications. Exploring fears related to breathlessness does not directly address the client's financial concerns.
5. A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?
- A. Check the tubing connections for leaks.
- B. Check the suction control outlet on the wall.
- C. Clamp the chest tube.
- D. Continue to monitor the client's respiratory status.
Correct answer: A
Rationale: In a closed chest drainage system, slow, steady bubbling in the suction control chamber is an expected finding, indicating proper functioning of the system. There is no immediate need for intervention as this indicates the system is working as intended. The nurse should continue to monitor the client's respiratory status for any signs of distress or changes. Checking tubing connections for leaks or clamping the chest tube are unnecessary actions based on the information provided. Checking the suction control outlet on the wall is also not indicated in this scenario.
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