ATI RN
ATI Detailed Answer Key Medical Surgical
1. A client with a tracheostomy is being cared for by a nurse. The client’s partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client’s discharge?
- A. Attending a class on tracheostomy care
- B. Verbally explaining all steps in the procedure
- C. Performing the procedure independently
- D. Asking relevant questions about suctioning
Correct answer: Performing the procedure independently
Rationale: When the partner can independently perform the suctioning procedure, it demonstrates a readiness for the client's discharge. This indicates that the partner has acquired the necessary skills and knowledge to provide safe care for the client at home without the direct supervision of healthcare professionals.
2. Which statement about the newborn baby's appearance is true?
- A. Girls tend to be slightly longer and heavier than boys.
- B. Their round faces and big eyes make adults feel like picking them up.
- C. The trunk is large in comparison to the head, and the legs are straight.
- D. On average, they are 18 inches long and 5½ pounds in weight.
Correct answer: C
Rationale: The correct statement about the newborn baby's appearance is that the trunk is large in comparison to the head, and the legs are straight. This is a common characteristic of newborn babies as their proportions are different from adults. Choice A is incorrect as there is no consistent trend of girls being longer and heavier than boys at birth. Choice B is incorrect as the perception of adults wanting to pick up babies is subjective and not a universal truth. Choice D is incorrect as the average length and weight provided may not apply to all newborn babies, as there can be variations.
3. The nurse is admitting a patient with a suspected fluid imbalance. The most sensitive indicator of body fluid balance is:
- A. Daily weight
- B. Serum sodium levels
- C. Measured intake and output
- D. Blood pressure
Correct answer: A
Rationale: Daily weight is the most sensitive indicator of body fluid balance because it can show trends over time, helping in assessing the effectiveness of interventions and medications. While serum sodium levels provide objective data on electrolyte balance, they may not accurately reflect fluid balance, especially if a patient is dehydrated. Measured intake and output are crucial for assessing fluid balance, but it can be challenging to match the two due to various ways fluid is lost from the body. Blood pressure and other vital signs may not always be reliable indicators of fluid balance as they can be influenced by other factors beyond fluid status.
4. When checking the intravenous (IV) site on a child, the nurse should take which action?
- A. Look at the site.
- B. Ask the child if the site hurts.
- C. Look at the site while palpating the area.
- D. Take all the tape off, assess the site, and redress.
Correct answer: C
Rationale: Looking at and palpating the IV site helps assess for signs of infiltration or infection, such as swelling, redness, or pain. Simply looking or asking the child may miss subtle signs, and removing all the tape unnecessarily disrupts the site.
5. A patient is prescribed a diuretic for hypertension. What is the most important assessment the nurse should perform?
- A. Monitor the patient's respiratory rate.
- B. Check the patient's blood pressure regularly.
- C. Monitor the patient's potassium levels.
- D. Monitor the patient's sodium levels.
Correct answer: D
Rationale: Corrected Rationale: When a patient is prescribed a diuretic for hypertension, monitoring the patient's sodium levels is crucial. Diuretics can lead to alterations in sodium levels, potentially causing complications like hyponatremia. While monitoring other parameters like respiratory rate, blood pressure, and potassium levels may also be important, the primary concern with diuretic therapy is the risk of sodium imbalance, making the monitoring of sodium levels the most critical assessment.
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