ATI RN
ATI Detailed Answer Key Medical Surgical
1. A client is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?
- A. Pain severity
- B. Wound drainage
- C. Tissue integrity
- D. Airway patency
Correct answer: Airway patency
Rationale: In a client following a partial laryngectomy, the priority assessment is always airway patency. This is crucial to ensure that the client can breathe adequately and prevent any complications related to airway obstruction. Monitoring airway patency takes precedence over other assessments such as pain severity, wound drainage, and tissue integrity. Any compromise in airway patency requires immediate intervention to maintain the client's respiratory function and safety.
2. While caring for a client receiving positive-pressure mechanical ventilation, which intervention should the nurse NOT implement to prevent complications?
- A. Elevate the head of the bed to at least 30°.
- B. Verify the prescribed ventilator settings daily.
- C. Administer pantoprazole as prescribed.
- D. Reposition the endotracheal tube to the opposite side of the mouth daily.
Correct answer: Reposition the endotracheal tube to the opposite side of the mouth daily.
Rationale: Repositioning the endotracheal tube to the opposite side of the mouth daily is not a standard practice and can increase the risk of complications, such as accidental extubation or damage to the airway. The endotracheal tube should remain in the initial correct position to ensure proper ventilation and prevent harm to the client. Elevating the head of the bed, verifying ventilator settings, and administering pantoprazole as prescribed are all appropriate interventions to prevent complications in a client receiving positive-pressure mechanical ventilation.
3. An emerging technique in screening for Breast Cancer in developing countries like the Philippines is:
- A. Mammography once a year starting at the age of 50
- B. Clinical BSE Once a year
- C. BSE Once a month
- D. Pap smear starting at the age of 18 or earlier if sexually active
Correct answer: D
Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.
4. The nurse is taking a health history from a 29-year-old pregnant patient at the first prenatal visit. The patient reports no personal history of diabetes but has a parent who is diabetic. Which action will the nurse plan to take first?
- A. Teach the patient about administering regular insulin.
- B. Schedule the patient for a fasting blood glucose level.
- C. Discuss an oral glucose tolerance test for the twenty-fourth week of pregnancy.
- D. Provide teaching about an increased risk for fetal problems with gestational diabetes.
Correct answer: B
Rationale: The correct answer is B. Given the family history of diabetes, the initial action the nurse should take is to schedule the patient for a fasting blood glucose level. This will help in assessing if the patient has developed gestational diabetes. Choice A is incorrect because teaching about administering regular insulin is premature without confirming the diagnosis. Choice C is incorrect as an oral glucose tolerance test is typically done earlier in pregnancy. Choice D is incorrect as discussing fetal problems related to gestational diabetes should come after a confirmed diagnosis.
5. Which of the following presents an important emerging challenge to changes in health care?
- A. Decreased immigration
- B. Nursing staff shortages
- C. Bioterrorism
- D. Increased surgical procedures
Correct answer: C
Rationale: Bioterrorism is considered an important emerging challenge to changes in health care due to its potential to disrupt healthcare systems, cause mass casualties, and create public health emergencies. Choices A, B, and D are not directly related to emerging challenges in health care. While nursing staff shortages are a significant issue, bioterrorism poses a different kind of threat that requires specific preparedness and response strategies.
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