ATI RN
ATI RN Adult Medical Surgical Online Practice 2023 A Questions
Question 1 of 5
A client has a newly inserted chest drainage system with a water seal. Which of the following actions should be taken?
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.
Question 2 of 5
In an emergency department, a healthcare provider is preparing to care for a client with multiple system trauma following a motor vehicle crash. What should be the priority focus of care?
Correct Answer: A
Rationale: In a client with multiple system trauma, airway protection is the priority focus of care. Ensuring a patent airway is crucial for oxygenation and ventilation, which are essential for maintaining vital functions. Without a clear airway, the client's oxygenation and ventilation could be compromised, leading to severe consequences. While decreasing intracranial pressure, stabilizing cardiac arrhythmias, and preventing musculoskeletal disability are important aspects of care, ensuring airway protection takes precedence in this emergency situation.
Question 3 of 5
When prioritizing client care after receiving change-of-shift report, which of the following clients should the nurse plan to see first?
Correct Answer: D
Rationale: When a client expresses being short of breath, it may indicate a serious condition requiring immediate attention to ensure adequate oxygenation. This client should be seen first to assess the severity of the situation and initiate appropriate interventions. The other options, such as awaiting transport for an x-ray, having a prescription for discharge, or receiving oral pain medication 30 minutes ago, do not present immediate life-threatening concerns compared to a client experiencing shortness of breath.
Question 4 of 5
During an assessment of the respiratory pattern of an older adult client receiving end-of-life care, which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations?
Correct Answer: A
Rationale: Cheyne-Stokes respirations are characterized by a pattern of breathing that ranges from very deep to very shallow with periods of apnea (temporary cessation of breathing). This pattern is often seen in clients near the end of life or with certain medical conditions affecting the respiratory control center in the brain. The alternating deep and shallow breaths can be distressing for both the client and caregivers. It is crucial for the nurse to recognize this pattern to provide appropriate care and support to the client and their family during this challenging time.
Question 5 of 5
A client has a chest tube in place connected to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?
Correct Answer: B
Rationale: The absence of fluctuations in the water seal chamber indicates that the client's lung has re-expanded. This finding suggests that the negative pressure in the pleural space is restored, preventing air from entering the system. Oxygen saturation, absence of pleuritic chest pain, and occasional bubbling in the water-seal chamber are important assessments but do not specifically indicate lung re-expansion.
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