ATI RN
ATI Medical Surgical Proctored Exam
1. When interviewing a client recently diagnosed with lung cancer and having a 60-pack-year smoking history, what is the most important action for the nurse to take?
- A. Educate the client about the importance of quitting smoking to halt cancer progression.
- B. Encourage the client to disclose both tobacco and marijuana use openly.
- C. Maintain a nonjudgmental attitude to promote honest communication with the client.
- D. Provide realistic information about cancer treatment and prognosis without giving false hope.
Correct answer: C
Rationale: Maintaining a nonjudgmental attitude during the interview is crucial to create a safe environment where the client feels comfortable and open about disclosing their smoking history and other relevant information. This approach helps establish trust and facilitates an honest conversation which is essential for providing appropriate care and support to the client.
2. When caring for an older adult client with a pulmonary infection, what action should the nurse take first?
- A. Encourage the client to increase fluid intake.
- B. Assess the client's level of consciousness.
- C. Raise the head of the bed to at least 45 degrees.
- D. Provide the client with humidified oxygen.
Correct answer: B
Rationale: Assessing the client's level of consciousness is the priority because it provides crucial information on the client's neurological status and response to the infection. Changes in consciousness can indicate deterioration or improvement in the client's condition, guiding further interventions and treatment.
3. A client with a spinal cord injury at T6 suddenly reports a pounding headache and blurred vision. What action should the nurse take first?
- A. Administer pain medication as ordered.
- B. Check the client's blood pressure.
- C. Place the client in a supine position.
- D. Increase the client's fluid intake.
Correct answer: B
Rationale: The client's symptoms of a pounding headache and blurred vision are indicative of autonomic dysreflexia, a potentially life-threatening condition in clients with spinal cord injuries at T6 or above. The nurse's priority action should be to check the client's blood pressure as autonomic dysreflexia can lead to severe hypertension. Identifying and addressing this elevated blood pressure promptly is crucial to prevent serious complications such as seizures, stroke, or even death. Once the blood pressure is assessed and managed, further interventions can be implemented to address the underlying cause of autonomic dysreflexia.
4. A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience should the nurse provide this service?
- A. African American churches
- B. Asian American groceries
- C. High school sports camps
- D. Women's health clinics
Correct answer: A
Rationale: The correct answer is African American churches. African Americans in the United States have one of the highest rates of hypertension globally. By providing services at African American churches, the nurse can effectively reach this priority population. While hypertension education and screening are essential for all groups, African Americans are the priority population for this intervention due to their disproportionately high rates of hypertension.
5. While caring for a client with extensive partial and full-thickness burns of the head, neck, and chest, which risk should the nurse prioritize for assessment and intervention?
- A. Airway obstruction
- B. Infection
- C. Fluid imbalance
- D. Paralytic ileus
Correct answer: A
Rationale: When a client sustains burns to the head, neck, or chest, the risk of airway obstruction is a critical concern due to potential swelling, inflammation, or inhalation injury. Any compromise to the airway can lead to severe respiratory distress or failure. Early recognition and intervention to maintain a clear airway are essential to prevent life-threatening complications in burn patients.
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