ATI RN
ATI Detailed Answer Key Medical Surgical
1. A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?
- A. The client who has been NPO since midnight for endoscopy
- B. The client who has left-sided heart failure and has a brain natriuretic peptide (BNP) level of 600 pg/mL
- C. The client who has end-stage renal failure and is scheduled for dialysis today
- D. The client who has gastroenteritis and is febrile
Correct answer: The client who has gastroenteritis and is febrile
Rationale: Gastroenteritis can lead to fluid loss through vomiting and diarrhea, especially when accompanied by fever. Fever can increase insensible water loss through sweating as well. Both vomiting and diarrhea can significantly contribute to fluid volume deficit, making the client with gastroenteritis and fever at higher risk compared to the other clients described in the options.
2. A nurse is providing dietary teaching for a client who has a burn injury and adheres to a vegan diet. The nurse should recommend which of the following foods as the best source of protein to promote wound healing?
- A. One cup of brown rice
- B. One cup of orange juice
- C. One cup of pureed avocado
- D. One cup of lentils
Correct answer: One cup of lentils
Rationale: Lentils are an excellent source of plant-based protein, essential for wound healing in a vegan diet. Brown rice, orange juice, and pureed avocado are not protein-rich foods like lentils and would not provide sufficient protein for wound healing in this scenario.
3. For a patient with obsessive-compulsive disorder (OCD) who spends several hours a day washing her hands, which type of therapy is most appropriate?
- A. Exposure and response prevention
- B. Dialectical behavior therapy
- C. Family therapy
- D. Interpersonal therapy
Correct answer: A
Rationale: Exposure and response prevention (ERP) is the most appropriate therapy for managing OCD. ERP involves exposing the patient to anxiety-provoking stimuli (such as touching dirty objects) and preventing the compulsive response (hand washing), thus helping the patient learn to tolerate the anxiety without performing the ritualistic behavior. Dialectical behavior therapy (DBT) focuses more on emotional regulation and interpersonal skills, making it less suitable for directly addressing OCD symptoms. Family therapy and interpersonal therapy may be beneficial for other conditions or relationship issues but are not specifically designed to target OCD symptoms like ERP.
4. Which statement about epidural analgesia is true?
- A. It numbs the entire lower half of the body.
- B. It limits pain reduction to the pelvic region.
- C. It strengthens uterine contractions.
- D. It shortens the length of labor.
Correct answer: B
Rationale: The correct statement about epidural analgesia is that it limits pain reduction to the pelvic region by blocking nerve signals from that specific area, providing pain relief during labor and delivery. Choice A is incorrect because epidural analgesia does not numb the entire lower half of the body. Choice C is incorrect because epidural analgesia does not strengthen uterine contractions; in fact, it may sometimes weaken them. Choice D is incorrect because epidural analgesia does not shorten the length of labor; it can sometimes prolong labor.
5. A nurse is caring for a client who is 1 day postoperative following abdominal surgery. The nurse should suspect that the client has developed an infection based on which of the following findings?
- A. Blood pressure of 110/70 mm Hg
- B. Temperature of 38.5°C (101.3°F)
- C. Heart rate of 92/min
- D. Drainage at the surgical site
Correct answer: B
Rationale: An elevated temperature of 38.5°C (101.3°F) is indicative of infection postoperatively. Fever is a common sign of infection, and temperatures above the normal range should raise suspicion. The other vital signs (blood pressure, heart rate) may be within an acceptable range, and some drainage at the surgical site can be expected postoperatively. However, the elevated temperature is a more specific indicator of a potential infection that requires immediate attention.
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