ATI RN
ATI Medical Surgical Proctored Exam
1. The client with a chest tube after a coronary artery bypass graft has significantly slowed drainage. What action is most important for the nurse to take?
- A. Increase the setting on the suction.
- B. Notify the provider immediately.
- C. Re-position the chest tube.
- D. Take the tubing apart to assess for clots.
Correct answer: B
Rationale: If the drainage from the chest tube decreases significantly, it may indicate a blockage by a clot, potentially leading to cardiac tamponade. The nurse's priority action should be to notify the healthcare provider immediately for further evaluation and intervention. Increasing suction, re-positioning the chest tube, or disassembling the tubing independently are not appropriate actions without healthcare provider guidance in this situation.
2. A nurse is assessing a client who is receiving morphine via a patient-controlled analgesia (PCA) pump. Which of the following findings should the nurse report to the provider?
- A. Respiratory rate of 20/min
- B. Oxygen saturation of 93%
- C. Pain level of 2 on a scale of 0 to 10
- D. Blood pressure of 110/70 mm Hg
Correct answer: D
Rationale: The correct answer is D because a blood pressure drop or other signs of morphine overdose should be reported, especially when using a PCA pump. Choices A, B, and C are within normal limits and do not indicate an immediate concern related to morphine administration.
3. Colleen found herself attracted to her psychology instructor. She would frequently go by his office just to be near him. When he didn't respond to her advances, Colleen eventually told him that she had thoughts of killing herself so that he would spend time trying to counsel her. What personality disorder best describes Colleen's thinking and behavior?
- A. Borderline personality disorder
- B. Schizoid personality disorder
- C. Schizotypal personality disorder
- D. Antisocial personality disorder
Correct answer: A
Rationale: Colleen's behavior of seeking attention and manipulating others by threatening self-harm to elicit a response from her psychology instructor aligns with the characteristics of borderline personality disorder. This disorder is characterized by unstable relationships, impulsive actions, and efforts to avoid real or imagined abandonment. Choices B, C, and D are incorrect because they do not match Colleen's behavior as described in the scenario. Schizoid personality disorder is characterized by a lack of interest in social relationships, Schizotypal personality disorder involves social anxiety and odd behavior, and Antisocial personality disorder is characterized by a disregard for others' feelings and violating their rights.
4. A nurse is reviewing the health history of a client who has a hip fracture. What risk factor should the nurse identify for developing pressure injuries?
- A. Frequent repositioning
- B. Poor nutrition
- C. Increased fluid intake
- D. Use of a special mattress
Correct answer: B
Rationale: Corrected Rationale: Poor nutrition increases the risk of developing pressure injuries as it impairs skin integrity and healing. Frequent repositioning, increased fluid intake, and the use of a special mattress are all important interventions for preventing pressure injuries, rather than risk factors for developing them. Repositioning helps relieve pressure, adequate fluid intake maintains skin hydration, and special mattresses redistribute pressure to prevent injuries.
5. A healthcare professional is providing discharge teaching for a client with type 2 diabetes mellitus. Which resource should be provided?
- A. Personal blogs about managing the adverse effects of diabetes medications.
- B. Food label recommendations from the Institute of Medicine.
- C. Diabetes medication information from the Physicians' Desk Reference.
- D. Food exchange lists for meal planning from the American Diabetes Association.
Correct answer: D
Rationale: Food exchange lists from the American Diabetes Association are a valuable resource for meal planning in diabetes. These lists provide guidelines for portion control and help individuals make healthier food choices. Personal blogs may not always provide accurate and evidence-based information. Food label recommendations are important but may not specifically address meal planning for diabetes. Diabetes medication information is essential but not the primary focus when educating about dietary management for type 2 diabetes.
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