ATI RN
ATI Detailed Answer Key Medical Surgical
1. The healthcare provider is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the healthcare provider that the chest tube is functioning properly?
- A. Fluctuation of the fluid level within the water seal chamber
- B. Absence of fluid in the drainage tubing
- C. Continuous bubbling within the water seal chamber
- D. Equal amounts of fluid drainage in each collection chamber
Correct answer: Fluctuation of the fluid level within the water seal chamber
Rationale: Fluctuation of the fluid level within the water seal chamber indicates proper functioning of the chest tube. This fluctuation reflects the normal ebb and flow of air and fluid in the pleural space, demonstrating that the system is maintaining the appropriate pressure. Continuous bubbling in the water seal chamber may indicate an air leak, absence of fluid in the drainage tubing suggests a blockage, and equal amounts of fluid drainage in each collection chamber are not expected in this system.
2. The site of chemical communication in the brain is the ________.
- A. neuron
- B. synapse
- C. axon
- D. dendrite
Correct answer: B
Rationale: The synapse is the correct answer. It is the site where communication between neurons occurs through the release and reception of neurotransmitters. Choice A, neuron, is incorrect as it is the cell itself rather than a specific site of communication. Choice C, axon, is also incorrect as it is a part of the neuron that transmits signals away from the cell body. Choice D, dendrite, is not the correct answer either, as dendrites receive signals from other neurons but do not release neurotransmitters for communication.
3. A nurse is caring for a client with thrombocytopenia. Which action is the highest priority to reduce the risk of bleeding?
- A. Use an electric razor instead of a straight razor.
- B. Apply pressure to any bleeding sites for at least 5 minutes.
- C. Avoid invasive procedures unless absolutely necessary.
- D. Monitor for signs of internal bleeding.
Correct answer: C
Rationale: The highest priority action to reduce the risk of bleeding in a client with thrombocytopenia is to avoid invasive procedures unless absolutely necessary. Thrombocytopenia is a condition characterized by a low platelet count, which impairs the blood's ability to clot properly. By avoiding invasive procedures, the nurse minimizes the potential for bleeding episodes that could be challenging to control due to the low platelet count. Using an electric razor instead of a straight razor (Choice A) is a good practice to prevent cuts, but it is not as critical as avoiding invasive procedures in this scenario. Applying pressure to bleeding sites (Choice B) and monitoring for signs of internal bleeding (Choice D) are important interventions but are secondary to the priority of preventing bleeding by avoiding invasive procedures.
4. What key contraindication should the nurse emphasize to a patient prescribed sildenafil (Viagra) for erectile dysfunction?
- A. Sildenafil is contraindicated in patients taking nitrates due to the risk of severe hypotension.
- B. Sildenafil should not be taken with food as it can reduce its effectiveness.
- C. Sildenafil is contraindicated in patients with a history of hypertension.
- D. Sildenafil should not be taken with grapefruit juice as it can lead to dangerous side effects.
Correct answer: A
Rationale: The correct answer is A. Sildenafil is contraindicated in patients taking nitrates due to the risk of severe hypotension. Nitrates and sildenafil both cause vasodilation, leading to a synergistic effect that can result in a dangerous drop in blood pressure. Choices B, C, and D are incorrect because there is no specific contraindication for taking sildenafil with food, having a history of hypertension, or taking it with grapefruit juice. The main concern is the concurrent use of nitrates with sildenafil.
5. The nurse is administering a beta blocker to a client with a heart rate of 58 bpm. What is the nurse’s priority action?
- A. Administer the beta blocker as ordered.
- B. Hold the beta blocker and notify the healthcare provider.
- C. Increase the dose of the beta blocker.
- D. Monitor the client’s heart rate and reassess in 30 minutes.
Correct answer: B
Rationale: The correct answer is B. A heart rate of 58 bpm is considered low, and beta blockers can further decrease the heart rate. Therefore, the nurse's priority action should be to hold the beta blocker and notify the healthcare provider for further assessment. Choice A is incorrect because administering the beta blocker without considering the low heart rate can worsen the condition. Choice C is incorrect as increasing the dose of the beta blocker can lead to further slowing of the heart rate, which is not safe in this situation. Choice D is not the priority action; holding the medication and seeking guidance from the healthcare provider is more crucial.
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