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: Continuous bubbling in the water-seal chamber
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. A client presents in the Emergency Department with chest pain. Which of the following conditions is least likely to cause chest pain?
- A. Arthritis
- B. Peptic ulcer disease
- C. Myocardial infarction
- D. Gastric reflux
Correct answer: A
Rationale: Arthritis is a condition primarily affecting the joints and is not known to cause chest pain. Peptic ulcer disease, myocardial infarction, and gastric reflux are conditions that can present with chest pain due to various reasons such as inflammation, ischemia, or reflux of stomach acid into the esophagus, respectively.
3. To best reduce the potential for risk, what type of atmosphere is needed to be developed?
- A. Nurse-focused
- B. Physician-focused
- C. Family-focused
- D. Patient-focused
Correct answer: D
Rationale: The correct answer is 'Patient-focused.' When aiming to reduce the potential for risk, it is essential to prioritize the needs and well-being of the patients. Creating a patient-focused atmosphere helps ensure that decisions and actions are made with the patients' best interests in mind. Choices A, B, and C are incorrect because while nurses, physicians, and families play essential roles in healthcare, when it comes to reducing risks, the primary focus should be on the patients themselves.
4. A nurse manager is asked to select clients for early discharge from the unit following a mass casualty event. Which of the following clients should the nurse manager recommend?
- A. A client awaiting a screening colonoscopy later that day
- B. A client whose discharge was cancelled the prior day because they developed respiratory distress
- C. A client who is 6 hr postoperative following an open cholecystectomy
- D. A client who is prescribed gastric lavage treatments to treat acute aspirin toxicity
Correct answer: A
Rationale: The nurse manager should recommend the client awaiting a screening colonoscopy later that day for early discharge following a mass casualty event. This client is stable and not in immediate need of hospital care. Choices B, C, and D involve clients who require ongoing monitoring and care due to recent developments or treatments, making them unsuitable for early discharge during a mass casualty event.
5. A client has a new prescription for Calcitonin-salmon for postmenopausal osteoporosis. Which of the following instructions should the nurse include in the teaching?
- A. Swallow tablets on an empty stomach with plenty of water.
- B. Watch for skin rash and redness when applying calcitonin-salmon topically.
- C. Mix the liquid medication with juice and take it after meals.
- D. Alternate nostrils each time calcitonin-salmon is inhaled.
Correct answer: D
Rationale: Calcitonin-salmon is commonly administered intranasally for postmenopausal osteoporosis. To ensure optimal absorption, the client should alternate nostrils daily when inhaling the medication. This practice helps prevent irritation and promotes consistent drug delivery through both nostrils. Choices A, B, and C are incorrect because calcitonin-salmon is not swallowed as a tablet, applied topically, or mixed with juice; it is usually administered intranasally.
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