ATI RN
ATI Detailed Answer Key Medical Surgical
1. While providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort, which of the following desired effects of medications should the nurse identify as most important for the client's recovery?
- A. It decreases the client's level of anxiety.
- B. It facilitates the client's deep breathing.
- C. It enhances the client's ability to sleep.
- D. It reduces the client's blood pressure.
Correct answer: B
Rationale: In the postoperative period following CABG surgery, deep breathing exercises are essential to prevent complications such as atelectasis and pneumonia. Opioid medications can depress the respiratory system, making it crucial for the nurse to emphasize the importance of deep breathing to maintain optimal lung function. While managing pain and anxiety are important, facilitating deep breathing takes precedence in this situation to promote effective recovery and prevent respiratory complications.
2. A client is 1 day postoperative following a lobectomy with a chest tube drainage system in place. Which finding by the nurse indicates a need for intervention?
- A. Chest tube eyelets not visible
- B. Continuous bubbling in the suction control chamber
- C. Presence of tidal fluctuation in the water seal chamber
- D. Development of subcutaneous emphysema
Correct answer: D
Rationale: The development of subcutaneous emphysema is a concerning finding that requires immediate intervention. Subcutaneous emphysema results from air leaking into the tissues, which can lead to respiratory compromise. It is important to address this issue promptly to prevent further complications. The other options are normal or expected findings in a chest tube drainage system. Chest tube eyelets not being visible may indicate dislodgement, continuous bubbling in the suction control chamber indicates proper functioning, and the presence of tidal fluctuation in the water seal chamber demonstrates appropriate drainage and lung re-expansion.
3. A patient is receiving discharge instructions after experiencing a stroke. Which instruction is most important for preventing another stroke?
- A. Take prescribed antihypertensive medications regularly.
- B. Engage in physical therapy exercises.
- C. Follow a low-fat, low-cholesterol diet.
- D. Attend regular follow-up appointments with the healthcare provider.
Correct answer: A
Rationale: The correct answer is to take prescribed antihypertensive medications regularly. Hypertension is a major risk factor for stroke, and controlling blood pressure through medication is crucial in preventing recurrent strokes. While physical therapy, diet, and follow-up appointments are also important aspects of post-stroke care, managing hypertension with medication takes precedence due to its direct impact on stroke prevention.
4. While caring for a client using O2 in the hospital, what assessment finding indicates that goals for a priority diagnosis are being met?
- A. 100% of meals being eaten by the client
- B. Intact skin behind the ears
- C. The client understanding the need for oxygen
- D. Unchanged weight for the past 3 days
Correct answer: B
Rationale: When a client is using oxygen, there is a risk for impaired skin integrity due to pressure from tubing. Intact skin behind the ears suggests that the client is not experiencing skin breakdown, meeting the goals for this diagnosis. The client's nutrition, understanding of oxygen therapy, and weight stability are important but do not directly relate to the priority diagnosis of skin integrity in this context.
5. A client is prescribed nicotine replacement therapy. Which statement should the nurse include in this client's teaching?
- A. Smoking while taking this medication will increase your risk of a stroke.
- B. Make a list of reasons why smoking is a bad habit.
- C. Stopping this medication suddenly increases your risk for a heart attack.
- D. Rise slowly when getting out of bed in the morning.
Correct answer: A
Rationale: When a client is prescribed nicotine replacement therapy, it is crucial to emphasize that smoking while using this therapy can increase the risk of a stroke. Smoking while on nicotine replacement therapy can lead to excessive nicotine levels in the body, elevating cardiovascular risks. Therefore, the nurse should educate the client on the importance of avoiding smoking while utilizing this medication. Choices B, C, and D are not relevant to the specific teaching required for a client on nicotine replacement therapy.
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