ATI RN
Adult Medical Surgical ATI
1. A client had a total hip arthroplasty. Which of the following prescriptions should the nurse verify with the provider?
- A. Administer enoxaparin 30 mg subcutaneously every 12 hr
- B. Place a wedge or pillow between the client's legs when turning.
- C. Instruct the client to restrict flexion of the hip past 120�.
- D. Encourage the client to perform foot and calf exercises every 2 hr
Correct answer: C
Rationale: Following a total hip arthroplasty, the client should be instructed to restrict hip flexion past 90 degrees to prevent dislocation of the prosthesis. Restricting flexion past 120 degrees is excessive and could lead to complications. Therefore, the nurse should verify this prescription with the provider to ensure the client's safety and proper postoperative care.
2. A client has a newly inserted chest drainage system with a water seal. Which of the following actions should be taken?
- A. Clamp the tube when the client is ambulating.
- B. Keep the collection device below the level of the client's chest.
- C. Carefully coil the tubes to prevent kinking.
- D. Position the client flat to avoid leaks in the tubing.
Correct answer: B
Rationale: Keeping the collection device below the level of the client's chest ensures proper drainage and prevents backflow of fluid into the patient's chest. This position allows gravity to assist in the drainage process. Clamping the tube when the client is ambulating can cause a buildup of pressure in the chest drainage system, potentially leading to complications. Carefully coiling the tubes is important to prevent obstructions and kinks that could impede the flow of drainage. Positioning the client flat may not be ideal as it could hinder proper drainage and increase the risk of leaks in the tubing.
3. A client with acute respiratory distress syndrome (ARDS) requires care planning. Which of the following interventions should be included in the plan?
- A. Administer low-flow oxygen continuously via nasal cannula.
- B. Encourage oral intake of at least 3,000 mL of fluids per day.
- C. Offer high-protein and high-carbohydrate foods frequently.
- D. Place in a prone position
Correct answer: D
Rationale: In acute respiratory distress syndrome (ARDS), placing the client in a prone position helps improve ventilation-perfusion matching and oxygenation. This position can optimize lung function and is a beneficial intervention for clients with ARDS. Administering low-flow oxygen via nasal cannula, encouraging oral intake of excess fluids, or offering high-protein and high-carbohydrate foods are not primary interventions for ARDS and may not directly address the respiratory distress experienced by the client.
4. When working as a professional nurse, what is the priority for a new nurse working on an inpatient medical-surgical unit with a preceptor?
- A. Attending to holistic client needs
- B. Ensuring client safety
- C. Avoiding medication errors
- D. Providing client-focused care
Correct answer: B
Rationale: The priority for a nurse working on an inpatient medical-surgical unit is to ensure client safety. This is crucial as errors in hospital care can lead to preventable deaths. While attending to holistic client needs and providing client-focused care are important aspects of nursing, ensuring client safety takes precedence to prevent harm and promote positive patient outcomes.
5. A client with chronic obstructive pulmonary disease (COPD) receives oxygen therapy. Which finding requires immediate intervention by the nurse?
- A. Oxygen saturation of 91%
- B. Respiratory rate of 10 breaths per minute
- C. Client reports shortness of breath
- D. Use of accessory muscles
Correct answer: B
Rationale: A respiratory rate of 10 breaths per minute in a client with COPD receiving oxygen therapy may indicate respiratory depression, necessitating immediate intervention. An oxygen saturation of 91%, client reports of shortness of breath, and use of accessory muscles are expected in COPD clients.
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