ATI RN
ATI Detailed Answer Key Medical Surgical
1. A client is unconscious with a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?
- A. Kussmaul respirations
- B. Apneustic respirations
- C. Cheyne-Stokes respirations
- D. Stridor
Correct answer: C
Rationale: Cheyne-Stokes respirations are characterized by periods of deep, rapid breathing followed by periods of apnea. This pattern is often seen in clients with neurological or cardiac conditions. Kussmaul respirations are deep and rapid breaths often associated with metabolic acidosis. Apneustic respirations are characterized by prolonged inhalations with shortened exhalations and can indicate damage to the pons. Stridor is a high-pitched, noisy respiratory sound usually associated with upper airway obstruction. Therefore, in this scenario, the client's alternating pattern of hyperventilation and apnea aligns with Cheyne-Stokes respirations.
2. A client with Parkinson's disease is prescribed carbidopa-levodopa (Sinemet). What should the nurse include in the teaching about this medication?
- A. Take the medication without a high-protein meal.
- B. Expect the medication to take several weeks to reach full effectiveness.
- C. The medication may cause urine to turn light.
- D. You may experience a rapid heartbeat as a common side effect.
Correct answer: B
Rationale: Patients prescribed carbidopa-levodopa should be informed that it may take several weeks for the medication to reach its full therapeutic effectiveness in managing Parkinson's disease symptoms. This delayed onset of action is important for patients to be aware of to prevent premature discontinuation of the medication due to perceived lack of efficacy.
3. When caring for a client with pneumonia, what intervention is most effective in preventing the spread of infection?
- A. Administer prescribed antibiotics on time.
- B. Encourage the client to use a tissue when coughing.
- C. Place the client in a private room.
- D. Perform hand hygiene before and after client contact.
Correct answer: D
Rationale: The most effective intervention to prevent the spread of infection when caring for a client with pneumonia is performing hand hygiene before and after client contact. This practice helps reduce the transmission of pathogens from one person to another, promoting infection control and maintaining a safe environment for both the client and healthcare provider.
4. A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience should the nurse provide this service?
- A. African American churches
- B. Asian American groceries
- C. High school sports camps
- D. Women's health clinics
Correct answer: A
Rationale: The correct answer is African American churches. African Americans in the United States have one of the highest rates of hypertension globally. By providing services at African American churches, the nurse can effectively reach this priority population. While hypertension education and screening are essential for all groups, African Americans are the priority population for this intervention due to their disproportionately high rates of hypertension.
5. A client is postoperative with shallow respirations at 9/min. Which acid-base imbalance should the nurse identify the client as being at risk for developing initially?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct answer: A
Rationale: The client's shallow respirations at 9/min indicate hypoventilation, leading to an accumulation of carbon dioxide in the blood, causing respiratory acidosis. In this scenario, the client is at risk for developing respiratory acidosis due to inadequate ventilation and subsequent CO2 retention.
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