ATI RN
ATI Detailed Answer Key Medical Surgical
1. A healthcare worker is caring for a group of clients in an infectious disease unit. The worker should wear an OSHA-approved N95 respirator mask when caring for a client with which of the following infectious diseases?
- A. Pertussis
- B. Mycoplasma pneumonia
- C. Tuberculosis
- D. Respiratory syncytial virus
Correct answer: C
Rationale: An OSHA-approved N95 respirator mask is recommended when caring for a client with tuberculosis due to the airborne transmission of the disease. Tuberculosis poses a higher risk of transmission via respiratory droplets, making respiratory protection essential to prevent exposure and infection among healthcare workers.
2. A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?
- A. Insert an indwelling urinary catheter.
- B. Inspect the mouth for signs of inhalation injuries.
- C. Administer intravenous pain medication.
- D. Draw blood for a complete blood cell (CBC) count.
Correct answer: B
Rationale: When caring for a client with burns, especially burns to the face and chest, the priority action for the nurse is to inspect the mouth for signs of inhalation injuries. Inhalation injuries can be life-threatening and may not be immediately apparent. Identifying these injuries early allows for prompt intervention and can significantly impact the client's outcomes. While other actions such as pain management and blood tests are important, assessing for inhalation injuries takes precedence due to its critical nature.
3. A nurse teaches a client with tuberculosis (TB) who is being discharged. Which statement by the client indicates a need for further teaching?
- A. I will take my medication as prescribed.
- B. I will need to have regular follow-up chest x-rays.
- C. I will be able to return to work immediately.
- D. I will use tissues to cover my mouth when I cough.
Correct answer: C
Rationale: Clients with tuberculosis should not return to work until they are no longer contagious and have been cleared by their healthcare provider. This usually requires several weeks of treatment. The other statements are correct and indicate understanding.
4. A client has a three-chamber closed chest tube system, and the water seal chamber rises with client inspiration. What action should the nurse take?
- A. Continue to monitor the client.
- B. Immediately notify the healthcare provider.
- C. Reposition the client to the left side.
- D. Clamp the chest tube near the water seal.
Correct answer: A
Rationale: In a client with a three-chamber closed chest tube system, a rise in the water seal chamber with client inspiration is an expected finding. The nurse should continue to monitor the client as this indicates that the system is functioning correctly. There is no need to notify the healthcare provider, reposition the client, or clamp the chest tube as these actions are not indicated in response to a rise in the water seal chamber.
5. Prior to a thoracentesis, what intervention should the nurse complete?
- A. Measure oxygen saturation before and after the procedure.
- B. Verify that the client has given informed consent.
- C. Explain the procedure briefly to the client and their family.
- D. Ensure informed consent has been obtained from the client.
Correct answer: D
Rationale: Before a thoracentesis procedure, it is crucial to ensure that the client has given informed consent. This process involves explaining the procedure, its risks, benefits, and alternatives to the client, and obtaining their signature on the consent form. Verifying informed consent is a vital legal and ethical step to protect the client's autonomy and ensure they have made an informed decision about the procedure.
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