ATI RN
ATI Medical Surgical Proctored Exam
1. A student asks the faculty to explain best practices when communicating with a person from the LGBTQ community. What answer by the faculty is most accurate?
- A. Avoid embarrassing the individual by asking questions.
- B. Don't make assumptions about their health needs.
- C. Most LGBTQ individuals do not want to share information.
- D. No differences exist in communicating with this group.
Correct answer: B
Rationale: It is essential not to make assumptions about the health needs of individuals from the LGBTQ community. Each person is unique, and assuming their needs based on their sexual orientation or gender identity can lead to incorrect care and communication. By being open-minded and avoiding assumptions, healthcare providers can create a safe and supportive environment for LGBTQ individuals to discuss their health needs openly and honestly.
2. A client has a pleural chest tube. Which action should the nurse take to ensure safe use of this equipment?
- A. Never strip the tubing to maintain patency.
- B. Secure tubing junctions with tape to prevent accidental disconnections.
- C. Set wall suction at the level recommended by the device manufacturer.
- D. Keep padded clamps at the bedside for use if the drainage system is interrupted.
Correct answer: D
Rationale: To ensure safe use of a pleural chest tube, the nurse should keep padded clamps at the bedside for use if the drainage system becomes dislodged or is interrupted. Stripping the tubing should never be done to maintain patency. Tubing junctions should be secured with tape, not clamps. Wall suction should be set at the level recommended by the device manufacturer, not the provider.
3. Which action should the nurse take to reduce the risk of ventilator-associated pneumonia in a client with an endotracheal tube receiving mechanical ventilation?
- A. Position the head of the client's bed flat
- B. Turn the client every 4 hours
- C. Brush the client's teeth with a suction toothbrush every 12 hours
- D. Provide humidity by maintaining moisture within the ventilator tubing
Correct answer: C
Rationale: Ventilator-associated pneumonia (VAP) is a common complication in clients receiving mechanical ventilation. Oral hygiene is crucial in reducing the risk of VAP. Brushing the client's teeth with a suction toothbrush every 12 hours helps prevent bacterial colonization in the oral cavity, which can be aspirated into the lungs. Positioning the head of the bed flat can increase the risk of aspiration. Turning the client every 4 hours is important for preventing pressure ulcers but not directly related to reducing VAP. Providing humidity in the ventilator tubing helps maintain airway moisture but does not directly address the risk of VAP.
4. A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take?
- A. Perform suctioning for up to four passes.
- B. Apply suction to the catheter when advancing it into the trachea.
- C. Preoxygenate the client with 100% oxygen for up to 3 min.
- D. Limit each suction pass to 25 seconds.
Correct answer: C
Rationale:
5. A client has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?
- A. Confusion
- B. Weakness
- C. Increased intracranial pressure
- D. Increased urinary output
Correct answer: B
Rationale: In myasthenia gravis, a neuromuscular disorder characterized by muscle weakness and fatigue, weakness is a common manifestation due to the immune system attacking the communication between nerves and muscles. Monitoring for weakness is crucial to assess the disease progression and determine the effectiveness of treatment. Confusion is not a typical manifestation of myasthenia gravis. Increased intracranial pressure and increased urinary output are not directly associated with this condition.
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